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rir in rLUUR rfAk= to <br />-- - • <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />W4 E W ESER AVE. 300 FLOOR <br />STOCKTON. CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIy1ES 90 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT PIPING REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />`...` EPA SITE # .---`----------- ---- -I PROJECT CONTACT•& TV- ------------- <br />PitOWE-#---�5� �� _C� L. J <br />------- ---------. --� - <br />C , ADDRESS ��� �7: + 1� .�� ► Ay_ ----------------- - ---------- <br />L I CRASS STREET ------- -'---------------------------------------------------i <br />T + OWNER--------- -----,-.---------- ----�--------- p HONE P / ' ,0 i�V i <br />-C ;-d7�T CUBA-! "_ - — _ {�_>...__t_►_ Cti---------------------- ONE #_ ZS2)_.5:S! - � 5 _! <br />j N I C OWPACTOR ADDRESS CA LIC -E -- <br />-- <br />A F,t{� 4 <br />-- -� 4--1----C?- -- -�------------------ -- �------- <br />1 T +-----------------• -----... WORK.COMP.# 1 <br />A-----------------------------------------------------------------------------------I <br />C OTHCR INFORMATION I I <br />--------------- ----' <br />----------------------------------- ---- ------ •------------------- <br />T{ <br />I------------- ------ I PROMS # <br />IO1 __ ..--------••----*----------------- -- -----i <br />;R ------------------------ <br />a••---------' � PHONE E i <br />i <br />I IIIIIIIIIIIIIiilillilllllll1111i -..-----------------------------------------------------I-------------------- 1 <br />•--- ' <br />TANK ID Y TALK SIZE I CHEMICALS STDREID CURRENTLY�PRB�►IOUSLY { OA1lEb UST INSfAS L8D <br />I 139- I v <br />IT139- <br />i A 39- I { <br />N 39- <br />j R 39- <br />I 39- I I 1 <br />---11191 ItIIIIItI i. 11111111 1�IIIItI.It. 1111111; 11111i IlliII I 11111;1 111111,���111111 iI� II111111 ��11111;;i <br />t <br />1pl <br />tt L I A APPROVSO WITH CONG=TION(S) DISAPPROVED <br />t A I ATTAC7LMENT WITH CONDITIONS) ' <br />I N I PLAN REVIEWERS NAME �- 12S&Z <br />' <br />+---1{Il liilll1111111111 I 111.11 ��� I1. 1111111 11111;1��111111 i"llllit�� 111111 ����1111 111�I;11 <br />APPLICANT MUST PER80" ALL WORK IN ACCORDANCE WITH SAN JOAQUII` COUNTY ORDINANCES, STATE LMS, AND RLrLBS AND REGULATIONS OF <br />SAN JOAQIXIDE COUNTY. ENVIRONMENTAL $SALTH DEPARTMENT. OWER OR LICENSED ACWT'S SIGNATURE CERTIFIES MW FOLLOWING, "I CERTIFY i <br />1 <br />THAT IN THE PEUEFORMANCE OF THE NO" FOR WHICH TELLS PERMIT IS ISM=, I SHALL NOT EMPLOY ANY PERSON IN SCTCs3 A MANNER AS TO I <br />M=ME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA-" CONTRACTOR'S EIkING OR 3GSCONTRACrIM SIGNATtiRE CERTIFIES TEIS 1 <br />FOLLOWING: "I CERTIFY TEAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMMPL.0Y PERSONS SUBJECT TO 1 <br />WORKER'S COMPENSATION LAWS OF CALIFO IA. " <br />TITLE DATE `s ii <br />APPLICANT'S SIGNATURE: I <br />, <br />`--------.._- ------------------ <br />-----------------------� <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit applicant, e.g_ property <br />owner, the party must acknowledge this responsibility for the billing by signature and dat below. <br />et LS� <br />�4� Sly (Zj 1V A� Phone # I -7.� �� <br />Name � Z— � � I�Address � <br />JV13L1ti CN <br />Sianature _ <br />EH230038 <br />(revised 1/39!02) <br />