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f <br />• • <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3"D 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 />----------------------------------------------------------- --------------------------------- + <br />EPA SITE # { PROJECT CONTACT & TELEPHONE # '7-- <br />------------------------------------------------ ------- - -4 `--/-)--------------t <br />{ F { FACILITY NAME ` ems- { PHONE -# % � � 3 - / { <br />-------------------------------------- <br />-7 r J <br />{ C I ADDRESS �^ 3 .!/!/ �(� G( /iL'-1-1 --------------------- <br />{ L { CROSS STREET [J�16?�iy1 <br />T { OWNER/OPERATOR { PHONE # <br />/- ---- <br />Y----------------------------- - C --------------------------- 4---f { t <br />----- ---------------------------------------- <br />{I C I CONTRACTOR NAME <br />--O---SLSPHONE # <br />'e- 3--07 S �_----- <br />+---------------------&- -------L--------------------------------- <br />N <br />----- -- <br />N I CONTRACTOR ADDRESS CA LIC # CLASS <br />T ----------------------------- <br />-------` - <br />- 'I <br />--1 <br />{ R 1 INSURER V { WORK.COMP.#�� �3 eQ <br />-- <br />IA t---------------------------------------- --------- ---------------------------------+----------------------------------------i <br />t C { OTHER INFORMATION { t <br />{--------------------------------------------------+----------------------------------------1 <br />I <br />{ 0 I I PHONE # t <br />IR+------------------------------------------------------------------------------------+----------------------------------------t <br />1 1 PHONE # I <br />___ 111 II I II 111111 <br />" II---------------------C-----------------------------------------------------------------------I <br />tllltlltltllttttttlltlllllltltll� <br />{ I TANK ID #t t TANK SIZE t CHEMICALS TORED CURRENTLY/PREVIOUSLY t DATE/ST INSTALLID { <br />! T I 39- <br />I <br />A <br />N <br />K <br />t P <br />{ L <br />t A <br />I N <br />I <br />1 <br />{ APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />I <br />I 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 />t BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />t FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />I WORKER'S COMPENSATION LAWS OF CALIFORNIA." t <br />39- I t <br />39- <br />39- t t t <br />39- { t t t <br />1 <br />39- <br />9IIIiIIIlllllllllllllllll I <br />1111 II 11 I I 111111 11111 1111 III 1111 II11111111111 111111 II IIIIIIIIIII 1111111 IIII III 111111111111111111 <br />I <br />I <br />APPROVED APPROVED WITH CONDITION(II DISAPPROVED <br />i <br />SEE ATTACHMENT WITH CONDITIONS) _J ` <br />PLAN REVIEWERS NAME �•��/�--�� DATE G C t <br />IIIIIIIIIIIIIlttttIIIFill l IIIIIIIIIIIIIIIIIIIIIIII1111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII11II11IIIIIIt1II M iII l11ill 1111111111 <br />t i <br />I ' <br />I <br />I I <br />APPLICANT'S SIGNATURE: L TITLE /;r,,. DATE <br />I <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 />own r, the party must acknowled tfais responsibility for the billing by signature and date below. <br />Name c3�-r-vie�� Address 62 E. /G' — _5 ��- ie�a�, , C,4 phone 5� 3� -6, <br />< T c <br />Signature <br />7 .1 <br />V t p f p t^ J� i' ear- <br />/� OL- <br />J v LL l aj-w to _ Z o y <br />�- 01 / f P Pj <br />n <br />s. <br />l �^C,j� <br />�U N► ! � <br />-tk �, S V Ke, <br />EH230038 <br />(revised 1/31/02) <br />3 <br />g,z, <br />A F ro P <br />OA CO) <br />L <br />L4'� <br />W <br />�- Z° �o�,�r��►Ib��s�P)iPt��rArl' v- <br />S <br />► <br />10. <br />Sc,(A Qb(� At' "O"tib "< <br />L4� �^. <br />�� <br />