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i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE. P FLOOR STOCKTON.CA 95202 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 REPAIR/RETROFIT -----------------------------------------------------------------------------------------------OJ-----------------------------------' I I SPA SITE # I PRECT CONTACT A TELEPHONE #Keith A. T a 1 1 i a i---------------------------------------------------------------------------- 2 -0m9 --7-5-4---}4&&-------------------------I I P I FACILITY NAME Norms 76 ----------------- -1 "'N"209-367-1795 { A+_____________ _ _ _ _-_-__-__--___--___-__--.-___-.-__-__-__-__--__--__-_-____--_-___---I I! ADDRESS--------- 6 3 3---E •---Victor __R d, { I LI CROSS STREET Lodi, CA 95240 1 1 I+----------------------------------------------------------------------------------------------------------------------------i I T I OWNER/OPERATOR I Mon # !YI Woolsey Oil Company t209-948-9412 t I-------- ----------------------- ---------------------------------------------------------+----------------------------------------1 ICI Co,:rRAaTOR' Oil Eouipment Service 1 PHONE#209-754-1808 I 10 •------------ --- - P "0 Box- g50 - - - ---------------------------------------------------------------------I I N I CONTRACTOR ADDRESS I CA LIC # I CLASS I T ---------------------- S -a ->Z GA ---9 5-24-9---------------- 3-2-3-4-11 ------------A-H a z----------- I I R 1 State Comp. Ins. Fund i NOR"•`' "" 265057 1 1 A ! ----------------------------- _----------------------------------------------------------------------------------------------- t I C I OTHER INFORMATION I t tT __________________________________________________________ _.-_----- I I D I I PHONE # I tR{____________________________________________________________________________________i--_____.-.__.-______________.__-_._-____I I i I PHONE # I {---{I{{IIIlIII1lltllliill11111111lI______________________________________________________________________________________________{ I 1 TANK ID # { TANK SIZE I CEBMMUS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I I 1 39- 1 10,000 1 Regular Gasoline I I T T 1 39- TAI39- 1 I I I IN139- I K 1 39- 39- p 9-39-P�// 1 I L I _ APPROVED _ APFlaOVED WITH IT ( ) , DISAPPROVED I 1 A ! I WI MONS) N I PLAN REVIEWERS NAME DATE I VO 1 ___{illllllilllllillllllllillllllfltlllllllllll111IIIIIIIIIIIIIIII111 illlllll{111111111111111111111111 IIIlfllll IIIItIIIIIIIII I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINAHM, STATE LAWS, AND RULES AND REGULATIONS OF I I SAN JOAQUIN COUNTY, 3XVIROWUMThL HEALTH DEPARTMENT. OWNER OR LIC8119ER AGENT'S SIGNATURE CERTIFIES THE FOLLOWING- "I CRRTIFY I PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.+ COiTTRACTOB'3 HIRING OR F,USOONTRACTING SIl87ATURE CERTIFIES 711E ! FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I COMPENSATION LAWS OP CALIFORNIA." I ! I I - { ! t I APPLICANT'S SI(1TMURE: TITLE Agent DATE 6 / 1 7 / 0 2 { Kei f fiL"'A. 1 f is 1 t---------------------------------------------------------------------------------------------------------------------------------- BILLING INFORMATION: THAT IN THE WORKER'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. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Oil Equipment P.O. Box 950 Name Service Address, n AnrtrPaS, ['A -9-52-4-1--Phone # 209-75,11-1808 f �.-7 .