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0 1 • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3RD FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FR�OM/THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: ____TANK RETROFIT _-)PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT + ------ + EPA SITE # PROJECT CONTACT & TELEPHONE # ' `n bb,O +___________ ____________________________________________ ----- F FACILITY NAME �� ___ y� PHONE # 11 A +_________________ Po ____ ___________________ _ C ADDRESS 3q � M/� � ) ) l� C_ 11 L 11 CROSS STREET ________Cl-------_ ______ _________________________ 11 1 I +_____________________ 111 1 T 1 OWNER/OPERATOR '1 PHONE # Y 1 _________________�.v�cl____C--V C-4 ________________________________ +-- _ q_ -� -I_______ - + Able- - 4 ►---- + - -- C CONTRACTOR NAME M i n I p �r-,e PHONE # -70-7 �y�_5saa 11 G +-------------------3D.;LCA on�z `"(nk_w Q laFf Z ct o N ! CONTRACTOR ADDRESS ) 1 CA LIC # CLASS 1 R INSURER " ,^ n� WORK.COMP.# _j1,1 1 A I_______________ _ _________________________________________________ 1 1 ____________ +_______________ �______________________11 C OTHER INFORMATION T +---------------------------------------------------------------------------------- U� cxroco� 0 PHONE # R +_________________________________________ ____________________+_____-_ ____________________11 1 1 PHONE # 1 +_--1111111111111111111111111111111111i1 11111111111111111111111111 I___ __________________________ ____ _ 11 TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY 11 DATE UST INSTALLED 39-__ 1 1 T 39-A 11 39-- 1 I 1 N 39 _ 1 I l I 1 11 K 11 39 .___ _- 1 1 _ 1 11 39- 1 1 I I 39- +___ 111111111111111111111111111111111111111 1 111111111111111-IIIIIIIIII 111111111111111111111111111111ilililll IIIIIIIIIIII III IIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIII V III IIIIIIIIIIIIIIII III IIIIIII1111111111 II 111111 I I IIII V III IIIIIIII P L APPRO APPROVED WITH CONDITION(S) DISAPPROVED A ACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE +___11111111111111111111 11111111111 111 II 11111111111111111111111111111111111111111111111111 1111111111 111 111111111111111111111 II I II III�IIII III 1111111 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII11111111111111111111111111 1111111111111111111111111111111111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 1 THAT IN THE 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 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA." 1 j I APPLICANT'S SIGNATURE: ��--� _1 � � TITLE I DATE 13 13/6 1 1 ----------------------------------------------------------------------------------------------------------------------------------- I BILLING INFORMATION: 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. NameSer_v►ce 5�4ion Sy5krn3%ddress_tg'j)_Gv,,6v,, ve._ n Phone # Q _ 1