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SAN JOAQUIN COUNTY EMOONMENTAL HEALTH DEPORTMENT 304 E WEBER AVE, 3"0 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: �TANKRETROFIT _PIPING REPAIR/RETROFIT __UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ------------------------------------------------------+ { I EPA SITE # I PROJECT CONTACT & TELEPHONE # h819i &,17n1n0 4#111-) US -1615-17001 {------------------------- - ---PHONE#--------------------------------I F ; FACILITY NAME 2D� I3d'� Ghevrorj fpr, I:dUG'4`-� C.O• I 1 1 A +------------------------------------------------- ------------------------------------ -----------------------------i I C I ADDRESS Iq&0 W. Ilfi- 5tree+ , Tracy- _1----------------------------------------------------- L - 8537& II +-------------------------------------------------- - - - -- - ----------------------------------------I L I CROSS STREET Corral HoIIOiJ Rd. II+-----------------------------------------------------------------------------------------------------------------------------I OWNWaMMEOR PHONE I T { Co. (Attn. David L ons i # q25 842 -4387 I Y I chevron Product--, ( Y� i I C I CONTRACTOR NAME rjavidgG Construction , Inc . I PHONE # (530) (22- (982 1 I0+-----------------------------------------------------------------------------------------------------------------------------1 N I CONTRACTOR ADDRESS 4 4 01 S Dn j 2 COU rt" F1=rjl{ I CA LIC # 755 84 8 I CLASS A, H AY- . I 1 T+-----------------------------------------------------------------------------------------------------------------------------I R I INSURER si-I a Comflen3?ticrl Insurance Fuhd I womcay.# 273 - 2oO3 + ---------------------------------------I C ; OTHER INFORMATION I I IT+------------------------------------------------------------------------------------+----------------------------------------I 1 0 i I PHONE # I IR+------------------------------------------------------------------------------------+----------------------------------------I I I PHONE # I +---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII----------------------------------------------------------------------------------------------I I TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I 139- 01 I 12.ono I rc_y. Jnl. I I492 . T T 139- 02 I 12 .not I M+d. uni. I 1iiS , I T A 139- 40 I 12- N 39- I I I I IK139- 39- 39- P 9_39-39-P I L I APPROVED APPROVED WITH CaIDI�IOPI(S) _DISAPPROVED A + N-IIIPLAN IIIREVIEWERS IIIIIIIIIINAME IIIIIIIIIIIIIIIIIII{IIIIIIIIIIIIIIIIIII{IIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIII IIII III11111111111 I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONSOF I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I I 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 OF CALIFORNIA.' { I I I I 1 4 40 APPLICANT'S SIGNATURE: 0 ~ _ - TITLE AAcnt %r ChC&on DATE 7/ _ 1 I C L Sftcoiln Of'/ Inc . +---------------------------------------------------------------------------------------------------------------------------------+ BILLING INFORMATION: THAT IN.THE 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. Name P,14L C4f.,> LO) n &_-; MIM il)z-. Address 1540 Arnold Dr. 0110 112rtinet Phone # U'5-313-1700 ®, 84553 ext 107 Sig 'FD � 4 �roy1 EH230038 1 (revised 1/31/02)