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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <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 # ; PROJECT CONTACT & TELEPHONE # <br /> F ; FACILITY NAME� / ` )O C ' HONE # 1 3 <br /> A +______________-//�J_�_____ /r�4___ __>�___�_�J _ =�Z�(1J�L_ rcr�_______ ___- ___7_�(0�_______, <br /> C ------S i1�"YY>l_� L�IcU__L=�_ 1 <br /> L ; CROSS STREET _ -so <br /> fi ' <br /> d so- - <br /> , I +------------'-'-- ------------------ ------------------------------------------------------------------------------' <br /> T OWNER/OPERATOR PHONE # <br /> Y S ' L She E' I� �3 <br /> ---+--------------�--- ----- --_- - -J--- - m--=-v-1/1L1�_n'` --p--- ---------+--------?Q ---- �_ -------- <br /> C CONTRACTOR NHONE <br /> AME 64 y� qi• f� _`� C 9 Q Y1C�_TQd 1I�� rvj L S------------ <br /> 1� �� /_ Y1 <br /> N CONTRACTOR ADDRESS d ' CA LIC # CLASS �, � C.u')1 Q Z <br /> _ __Z __'Z_ c__1_gma�- ---------- - -------'--------- 7 j- <br /> T +-------'------------ - -- - - - '-- - -- - - - /-- --- <br /> R INSURER rt <br /> ' WORK.COMP.# ' <br /> A '---------- ---- -1.Rm1S(d�oo_Ze�S�ar �_ --------------------- Iav3 '2-----------; <br /> +------------------- <br /> C OTHER INFORMATION <br /> O PHONE # <br /> PHONE # <br /> -----------------------------------------------------------------------"--------------------- <br /> �y-„ jANK ID # ..// TANK SIZE{ CHEMIC,L STORED CURRENTLY/PREVIOUSLY ; DATE US I STALLED <br /> 39-4d�y.�1� D`J7�Y !ST(jD6A&bot1S ;UYI�AIAP�(f�'�fir)t <br /> T ; 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> I A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <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 /> 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 <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.” <br /> t-1-ee f l&Ya/f/�iY►�a - <br /> APPLICANT'S SIGNATURE: �' TITLE �/h fen e it- DATE02-OU <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 date below. <br /> Name Address Phone# <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />