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SAN JOAQUIN COUNTY EN,,, 204 ENVIRONMENTAL HEALTH 304 E WEBER AVE, 3RD RDEPARTMENT PV(r,/. t SFRt yEACTy STOCKTON, CA 95202 v7i, (, APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT �`JJ THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: TANK RETROFIT Oj_PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +---------------------------------------------------------------------------------------------------------------------------------+ EPA SITE # I PROJECT CONTACT & TELEPHONE # MIW 1(A9VeL p-r2,oq gas 7628 1 +_________________________________________________________________________________________ ____________________________I Lo j F I FACILITY NAME �/ K Star I � _ ___________________________________ 1_ PHONE # �'1 w 9 :r 3 - 76*P Q A+--------------------/-�-�----�-,-/A- - - /� ----- -----------------------------_--------i C ; ADDRESS SOS / V - A4,41 N� i� A I+__________________________________ _ ________________ _____ _/---___________________ ________i L ; CROSS STREET jI +______________________ _____ ______________________________________________________i T OWNER/OPERATOR PHONE # Y CQ-�[ [ .s'--------------------------------- 70--9f - 823 --7dzk -- +------ 1 C I CONTRACTOR NAME �'P/� (/�� A �r�� /yy� ////� /` M �w� /1L PHONE # I O 7 0 +-----------'-------- ---------------- --------------- --------------I N ; CONTRACTOR ADDRESS \A /.6 ()r,QAWK___BLV% CA LIC # 67'( 77 / CLASS A C 10 1 1 R 1 INSURER 1 WORK.COMP.# 1 !r -<-5V02 "( 1 - -O C OTHER INFORMATION T+____________________________________________________________________________________+________________________________________I 0 i i PHONE # R+____________________________________________________________________________________+________________________________________I PHONE # ______________________________________________________________________________________________I TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 1i 39- T 39- A 39- N 39- li K , 39- 39- 39 - IPI ; L II APPROVED 1� APPROVED WITH CONDITION (S> DISAPPROVED ; ; A I (SEE TTACHMENT WITH CONDITIONS) ; N PLAN REVIEWERS NAME {�/ ��-�DATE +___1111 IIIIII111111111111 I III IIIIIIIII IIIIIIII RIIIII II1111111111111111111111111 II11111111111111111 IIIIIIIIIIIIIIII1111111111 IIII11111111111111111 1111111111111111111111111111111111111111111111111111111111111111111111111111 IIIIIIIIIIIIII II (IIIIIIIII I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO ; BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE DATE? -y -40 THAT IN THE WORKER'S . � � BILLING INFORMATION: 1, -rk+ i'� v °'`�4 ' Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NameAddressg_Phone # S1 Y 81e7,17-20_ 1