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SAN JOAQUIN COUNTY RECENED
<br /> ENVIRONMENTAL HEALTH DEPARTMENT MAY 9 2006
<br /> 304 E WEBER AVE,3RD FLOOR
<br /> STOCKTON,CA 95202 ENVIRONMENT HEALTH
<br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT PERMIT/SERVICES
<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 /> EPA SITE # PROJECT CONTACT & TELEPHONE #
<br /> +---------------.---------------------------------------------------------------------- - - ---
<br /> F ; FACILITY NAME 1tU- --- - '7 / /? q
<br /> ; A +-------------------------- li _ U PHONE # � `7
<br /> ---- --------------- 7 U 7 7- 3
<br /> C ; ADDRESS L`l '
<br /> I -------------------------------------------------
<br /> L
<br /> ------------------------------------�� L!--N
<br /> -------------------------------------
<br /> L CROSS STREET
<br /> T ; OWNER/OPERATOR
<br /> Y ; PHONE #
<br /> ,
<br /> ,
<br /> ,
<br /> C ; CONTRACTOR NAME /n / � -------'-'-------+------------------`------------/-___------
<br /> O +--------- _mac"YIG��Gl ; PHONE #
<br /> N CONTRACTOR ADDRESS //�� - / ''/ /' / 7 p -----------------------------
<br /> T +---------- 1(1_�-Z �_SrS�1�?."✓Y✓` 1� ,(-,lA, _ CSiU CA LIC fi C / U CLASS
<br /> R INSURER - � .---- - - ._1_1_ _S------------- ( t- '
<br /> A ; - yGl/ti(C-- Cr', S.T_ �_-- -�U--------------------------------------------- WORK.COMP.#- `7 ZoSJ ----------
<br /> h -
<br /> T 4 C ; OTHER INFORMATION -
<br /> --
<br /> ,
<br /> ----------------------------------
<br /> ,
<br /> PHONE #
<br /> + —
<br /> ---------------------------------- ------ ---------------------------------
<br /> , PHONE u
<br /> ----------
<br /> TANK ID # TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED
<br /> 39-
<br /> T 39-
<br /> A 39-
<br /> N 39-
<br /> K 39-
<br /> 39-
<br /> 39-
<br /> +-L- ;ED' ;;;;;;;;, I;I;,;IIII;;;;,;,, , ,, , ,,,,,,,,,, ,, ,„ ,,, ,, , ,,,, , , , , ,, ,,,,, , ,, ,,, ,,
<br /> APPRO
<br /> APPROVED WITH CONDITION(S) DISAPPROVED
<br /> A ( E ATTACHMENT WITH CONDITIONS)
<br /> N PLAN REVIEWERS NAME,, ,,,,,,, , ,, ,,„� , ,, ,,,, ,, DATE, ,, , ,,
<br /> :_N_,
<br /> PA
<br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF
<br /> 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 /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE
<br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO
<br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA."
<br /> APPLICANT'S SIGNATUR TITLE 614 L4' 11 �4C Wl,-e- DATE -5r-/
<br /> ,
<br /> +-------------------
<br /> -------------------------------------------'--------------------------------------------+
<br /> BILLING INFORMATION: W,-(I,
<br /> ,j Co Y" P U,"j
<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 /> owner, the party must acknowledge this responsibility for the billing by signature and date below.
<br /> Name Address Phone #
<br /> Signature
<br /> EH230038
<br /> (revised 1/31/02) Uf9,1,, iAAAP
<br /> 1
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