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n U SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, P FLOOR STOCKTON, CA 96102 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: TANK RETROFIT ---PIPING REPAIR/RETROFIT ____UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT +-------------------- ----------------------------- ------------------------------------------------------------------------------- I I LTL SITE Y I PROJECT CONTACT E TL,LTHONS # I I+--------------------------------------------------•--------------------------------------------------------------------------I P I FACILITY NAVE Norms 76 I vA= r 209-367-1 795 I IA*---------------------------------------------------------------------------------------------------. ------------------------I I c I ADDREss 633 E. Victor Rd., Lodi, CA 95240 I II+____________________________---•______----_.-_-----_.--.-_-_-_-_-_-.-_-----______---_----______-___-----__-_._-_•__-__---_-._I I L l aws sT = Cherokee 1 II +__________________________________________________________ I T I OMIWOPSRATOR Woolsey Oil Company I PHONE • 1 1Y1166 Frank West Circle, Stockton, CA 952061 209-948-9412 h t I---+-------------------------------------------------------------------------- +------------------- I c I cl* ' C7OR —Oil Equipment Servicer 209-754 1 808 1 O +-------------------- P : ©� "$ox-9�fi------------------------------------------------------ ------------------------- I N I OMTRWM ADDRBSe 1 CA LIC N 323417 I `T'Ass A -H a z C 1 0 San__Andr_eas,____CA___9.5Z_9---------------------------------•-------- I I R 1 D State Com -- Ins Fund I WOpl-coNP.11 265057 I A I----------------------------------------------------------------------------------*----------------------------------•----- I C I OTHER INFORMATION I 1 T+____________________________________________________________________________________+_.._______.__- _.---.-___-____--_-_-_-I 1 0 1 1 PHONE N 1 1 R+____________________________________________________________________________________+.______..__------__---_-_-_._._-_-------I I 1 I PHONE N I + -III{111111111111111111111111111I----------------------------------------------------------------------------------------------I I TANK ID S 1 TANK SIZE I CBENICAI.S STORED CURRMMY/PREVIOUSLY I DATE DST INSTALLED I I 1 39- I T f +1II1II-P--11lI l3l9l- AI39- N 39 - x139- 39- 39 - L 9 -39-39-L lllllllllittlllllllllllllllIIIII1 lllllllllllll^ll,��l_lllilljllllllllli1(IIII tiilillllllllllDlIlSlAlPlPlR101VlElD RIOlllllllllIIIIII lllllllllllllllllilllIiItl1II APPROVED 1 T AI REVIEWS" D(sLe �Tf� poerolTIOas1 � 1 1 1 N 1 PLAN RENDNAlB Yi1�'UI'('1 u AJC DATE V I +'--IIIIIIIIIIIIIIIII11111111 III111111 11 IIIIII�11111 Ililllllll IIIIII111111111111111111111111111111 1111111 llillllil{11111 I I APPLICANT MUST PURFOPN ALL WORK IN Acawmwm WITH SAN JOmm COUN17 ORDINimm, s1'ATE LAWS, AND RULES AED axam 1TIONS OF I I SAN JOAQUIN COUNTY, SMVIRO UUML REAM DRPAET1iHP. Omm OR LICA UINL►P'S sIOS►TURE CLCTiFI s TIO FOLLOWINGt -I CLRTIFY I I PERPOR14ANK7 OF THE WORK FOR MACH THIS PUREST IS ISSUED, I MWI NOT SNPLOY ANY PERSON IN SUCH A HRMU AS TO 1 I BSCQME SUM= TO WOR1='S CQUOUSATION LAWS OF CALIFORNIA.- 0002ACTOt'S HIRING OR SUBOONTIRACTING SIGWATURB CWrIFISs THE I FOLLOWING. -I CSRTIFY THAT Zh- OF THS R WHICH THIS PERMIT IS ISSUED, I SHN�t.L BNPSL)Y PUMM SOEJSLT TO I I CXNPENSATIOi LAWS OF CALI I I 1 1 1 Agent I APPLICANT'S SIGNATURE: TITLE g DATE 8 2 1 0 2 j Ilia+------------------------------------�--- i--------------------------------------------------------------•-------+ BILLING INFORMATION: � r Q cl C4,'f ec/ THAT IN I= WORZOR'S Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment. coverage per tank. If the party designated below is different than the permit applicant, e.g. properly owner, the party must acknowledge this responsibility for the billing by signature and date below. Oil Equipment P.O. Box 950 Name_ ___._. phone#209-754-1808 -� _Address ��,,. __ndr-e GT 95249 _ 1