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• � RECENED <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT JUL 2 8 2004 <br />304 E WEBER AVE, 3RD FLOOR <br />STOCKTON, CA 95202 ENVIRONMENT HEALTH <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT PERMIT/SERVICES <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+----------------------- --- ----- ------ --- --------- -- --+ <br />EPA SITE # 1 PROJECT CONTACT & TELEPHONE # <br />+_____________________________ _________ ______ ___-___-______ ____________________, <br />F ; FACILITY NAME - PHONE # <br />A ----------------- ------ <br />-------- ------------------------- ------ <br />C ADDRESS \ �- M_�___�� j- <br />`.. -Yr!---\ _�L 111 <br />I +___________�_ __ �_ ________--------- _______________________________ <br />L ; CROSS STREET <br />I+__________________________________ -_____ _--___-_________________________________ <br />T OWNER/OPERATOR PHONE # <br />Y <br />,___ ________________ _ ______________________________+______ _________________-___ <br />C 1 CONTRACTOR NAME. PHONE # <br />�----v-�------------------------- �;-�- <br />O +----------------- �^ --- - -------- <br />N <br />\ N CONTRACTOR ADDRESS-- �-�\ _ ^ ` __ \ ,� -� LIC # �& -CLASS------------------- <br />R INSURER® \ ___________________________+------------a! <br />C OTHER INFORMATION <br />T+- -------------------------- ---------- -+----- -------------------------I <br />0 I , PHONE # <br />R+___________________________________ -_________ <br />PHONE # <br />------- ---------------------------- ----------- ------------------- <br />'I,1I " II TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />,,,,,,,,, <br />P <br />L ! APPROVED X APPROVED WITH CONDITION(S) DISAPPROVED <br />A (SEE 'ATTTTA_CHMENT WITH CONDITIONS) ` <br />N PLAN REVIEWERS NAME �wi� / /__ DATE (J <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISS I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />BECOME SUBJECT TO WORKER'S COMPENSA N LAWS OF CAL ORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNAT7P.E CERTIFIES THE , <br />=LOWING: 'I CERTIFY TH i IN THE PER C OF THE,ICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />COMPENSATION LAWS OF CALIFO <br />APPLICANT'S SIGNATURE: TITLE v� \� DATE 1( C <br />���� / <br />__-_____ ___________ ______________+ <br />BILLING INFORMATION: <br />THAT IN THE <br />WORKER'S <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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name Address Phone # <br />