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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, SAD FLOOR STOCKTON, CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: TANK RETROFIT _PIPING REPAIR/RETROFIT ---UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +----------------------------------------------------------------------------------------------------------- ---+ I I EPA SITE R____'_______________________'-___ _PROJECT (�1NTACT & TELEPHONE # Nic R A4 E L WA (• o A.f gip -343 I-----------'------------------------------------------------------------------'---i P I FACILITY NAME / S ' f PHONE A--------------------U --_--" 0 ----_^.__'-"---------------------------------- ------------- S'o s i I c I ADDRESS h(- XA A: l r( S �' ---- --- A I�1 _ F !°► - - --9 3} 1 1 I L I CROSS STREET I+_____________________________________________________________________________________________________________________________I I T I OWNER/OPERATOR I PHONE k I Y I Q v t VG S7-00 v" AIL le F, -r- s --------------------------------------------------------------------------------- +- I C I Ca ITRACTOR NAM$ I PHONE " 9l b` (!c/Ar.'r0w( E�l.►��,�n`"`��------"`-4-=------------------ N - -- ---------- ---------------------------------I 1 O +------------ ------------------------------ 2 --- x i CONTRACTOR AI)DR83s �' II �x� A 6 9! Ica LIC >R 6 Z 3 $`--- - S A "ot Z 1 IT ------------------------- •-------------�----- If 3=-------------------------------------�---_--------- I R I INSURER �j T A -TE Fu �.c. I `ORK.00"�'_" � 13 `F 9 z 3- 0 3 AI ------------- --------------------------------------------------------------------- - ----- ------ C i OTHER INFORMATION ---------------------------------------------------------- I O I ( PHONE k 1------------------------------- I PHONE Y I +___Iiilllliillllllllllllllfllllllll______________________________________________________________________________________________1 I TANK ID N I TANK SIZE I CHEMICALS STORED CURJDMY/PREVIOUSLY I DATE UST INSTALLED I 1 139- d l I /O.00 c I (;aSoCAr4� �} I UAlK 1 T i 39- O A i 39- D 3 1 g„(AO e I �.4-SO L AALR 4l I C.lA(K N i 39- I I I 1 K i 39-_I I I 1 1 39' ( I 1 139' I I I +---IitIIIIIIiIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIiiIIIIIIIIIIIIIIIIIIfIIIIIIIIIIIIIiIIIIIfIIIIIIIIIIIIIIIIIIiIIIIIIIiIIIIIIIIIIIIIII PI I L 1 _ APPROVED � APPROVED WITH CbNDITION(S) DISAPPROVED I 1 A1 SEE ATT STf WITH CONDITIONS) I N I PLAN REVIEWERS NAME llDATE +---11111111111111111111111 II IIIII IIIII1111111'1lllllllllllllliilllllllllllllllllllllllilllllllllll IIIIIIIIIIIIIIIIIIIitlll 1 I I APPLICANT MIST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I SAN JOAQUIN COUNTY, ENVIRM04TAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I I PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I I BECOME SUBJECT To WORM.5 COMPENSATION LAWS OP CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I 1 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." I 1 1 IZ_�o I APPLICANT'S SIGNATURE: TITLE �2 ! V� DATE yuleµcE�---._ -----------------------------------------------------------I+ BILLING INFORMATION: THAT IN THE WORKER'S 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. P.0 " BOX /o2S' �tid NameA-,Qtcj- 0K-_Address W -Phone