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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3RD 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 --'o PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ---- -- ---- +---------------------------------------------------------------------------------------------------------------- -- ---------+ EPA SITE # I PROJECT CONTACT & TELEPHONE # crv. � ��-- i I+--------------------------------------------------------------------------------------------------------------------I FI FACILITY NAME v�'� I PHONE # j - qq 2 —) 1 A ------------------ ,-� ---W ------ --------------------------------------------`--------------- -- -----, C I ADDRESS I -------------------17 - N - __ -- --- ----5 ----- 5 ! L I CROSS STREET frt AA 0y1+ S+ I II + ---------------------------------------------------------------------------------------------------------I I T I OWNER/OPERATOR Gy n�.�2� 5• �1Q. ' Y I �/i #tog - q q Z-) 7 3'� I---+------------------ u--.-e-- ------------- ----------------------------+-------------------------- ---- ---- C I CONTRACTOR NAM -- -V1neer�n��ra.Q�nel�# �,%o�-201 10 ---------------------------------------------- _ ---- N ,II I CONTRACTOR ADDRESS A ,w ' (CLIC # glI�IZ----I-�--SSS-- T +______________________ -_-- _________________-._____________-C.I ------ R I INSURER fij-�Aj I WORK.0 -# 60694-6.-'03 A1------------------- - -----•'----------I--------------------------------------------+--------------------------------------`I C I OTHER INFORMATION I I T+________________________________ --__-_--_-___+-_-___________________________----_-----I I D 1 1 PHONE # R+_-_---.____..----.......---,..---- ---- .----..-__--___._______________,.____-__----_ ---------------- ------------ I PHONE # +___illliilllllllllllllllillllllllll_________________________________________________________________________I i CHEMICALS, STORED jRRFNTLY/PREVIOUSLY I DATE UST INSTALLED f 14W_ 1 (/r/[/ i I A l 39 I I I I ( T N I 39- I K 1 39- I I I t I 1 39- I 1 39- I I I I +---Illllllllllllllllllllllllllllllllllllflllllllllllllllllllllllllllllllllllllllllllllllllllltllltlllllllflll111111111111111tlllll JPI I L I APPROVED APPROVED WITH CONDITIONS) DISAPPROVED T A I l + NIIPILIAINIIRIEIVIIIEIWIEIRISIINIAI�II�IIIYP%�,1IIIII�II,IIIIIlII/f�ILfIIIIIWIIITIIHICONDITIOSJill)IIDATE IIIIIINIIIIIIIIIIIII�III—III'I/Ij IIcjI/�I IIIIIIIIIIIIII I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COMM. ENVIRQ49NTAL HEALTH DEPARTMENT_ OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I I THAT IN THE PERFORPWNCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOr EMPLOY ANY PERSON IN SUCH A MANNER AS TO I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I f I 1 APPLICANT'S SIGNATURE: TITLE VA) 141DATE +____________________________ _------------------------------- ----------- -----_-_ -j---_-_-___________-_I BILLING INFORMATION: 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 mus--rr__ ta__cknowledge this responsibility for the billing by signature and date below. Name_ !r -Address_ W1 I SQvl W c5tl�.n Phone #912-1-734 1