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1 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3PD 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 )L --PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />1 EPA ID #CA2890090002 <br />+----------------------------------------- <br />F 1 FACILITY NAME LLNL-Site 300 <br />A------------------------------------------- <br />c 1 ADD"ES3 Corral Hollow Road, <br />I+ ------------------------------------------ <br />-------------------------------------------------------- ------------------------ <br />PROJECT SDNTACT& L -p --NE_- <br />-_Shar-i__Rr-igd-Qn-_(425_)___423-7-665-_; <br />1 PHONE # X925) 423-7665 <br />------------------------------------------------------------------------- <br />Tracv, CA 95376 <br />L , CRCSS STREET 1-500 <br />T 1 aNNER/OPERATOR1 » # (925) 422-7481 <br />,Y: U.S. DOE/UC LLNL, Beverlee Morales ; , <br />+-------- --------------------------------------------------- <br />c <br />PHONE <br />i I co" `Thornton & Son Electric # 2 09) 834-792H -------------------------------(--- - <br />------- <br />N 1 <br />1 CONTRACTOR ADDRESS' <br />1 T --------------------- Q- B�_x 3�SI$33x__i_],�,as_T9Q LIc-51�--------' <br />R 1 INSURER 1 WORK.COHP.# 1 <br />A 1 ----------- Gr-eat_American__In.suran.ce.-_Co---------------------------+------------Exempt-_Cer-t-------- <br />1 <br />C 1 OTHER INFORMATION i 1 <br />1 <br />' T +------------------------------------------------------------------- <br />1 0 : 1 PHONE # 1 <br />iR ---------------------------------------------- ---------------------------------------+----------------------------------------i <br />1 PHONE # i <br />+-__11111111111111111111111II1111111-------------- ---------------------------------------------------------------'-----------------i <br />11111111111111111111111111111111 <br />SIZB 1 Cma STORED Y/P OUSLY 1 DST TALLER 1 <br />39_0001119'W 0505181,1 15,(x' gal regular un ea e m ;'June V : <br />i T 1 39- <br />l A l 39- <br />i N l 39- <br />1 1 <br />1 X 1 39- <br />39- <br />39- <br />+---III llllkl 11 llllllllllllllllllll I1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <br />1 p 1 1 <br />i L 1 APPROVl3D _ APPROVBD WITH COND T (S) _ DISAP71! <br />i <br />1 A <br />N ; PLAN TUMMU IBR3 111111 11111 1111111111111111111 11111 11111111111111 <br />1 <br />1 1 <br />' APPLICANT MOST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDnwxz3, STATE LAWS, AND RULES ANO REGULATIONS OF <br />'. <br />1 ' <br />1 SAN JOA(711IN COUNTY, L2IVIROL =TAL HE'% rH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGS "I CERTIFY <br />pERFORMANCB OF THE WORK POR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PBRSON IN SUCH A HAMM AS TO 1. <br />BPX'om 3UBJECP TO WORKER'S ComPENSATION LAWS OP CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 <br />1 FOLLOWINGS "I CERTIFY THAT IN THE PERPOF44MCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PEHSONE SUBJECT TO <br />COMPENSATION LAWS OF CALIFORNIA." 1 <br />THAT IN THE <br />1 WORKER'S <br />1 i <br />1 , <br />1 - 1 <br />APPLICANT'S SIGNATURES ' .. TITLE / �&y- lL1ZC�_'3.� DATE - i2 /c Y 3 <br />1 �J <br />------------------------ ---------------------------------------------------------------------- zi-2 -----------------------------+ <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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name Shnri Rri gdnn AddreSspn Rnx mg, T-677 Phone #995 T493-7669 <br />1 <br />