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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3" FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />_TANK RETROFIL,�A{PfNG REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />--------------------------------------------------------------------------------- - ------------ - + <br />PROJECT CONTACT & TELEPHONE # -��� i (.`„- 33s <br />EPA SITE #--------------------------------- FsY/�l- - <br />+- --------------------- --- _ - t 26LWW'--------�_ <br />F FACILITY NAME 5 PHONE # /� -- <br />'------- �---- 1--�- -- - - 1C/'• Jam' <br />C ; ADDRESS , (r`Z <br />I+----------------------------- -- ---�J------E-rt - — C� , <br />L :_CROSS STREET^-_, <br />uV <br />PHO <br />; -T OWN _ �� ------------- NE # --- <br />//-- ------------------+----- --- (,( L�j <br />C , CONTRACTOR NAME PHONE # <br />0 +--------------- s ' l:lcac --- �#� -n-Q- � - C) -Z <br />N ; CONTRACTOR ADDRESS CA LIC # 1 CLASS <br />---- <br />R INSURER s0�'LL COMP. -C/ <br />`���q_- J---- <br />------------A ------- ------ --------------- ------// <br />C OTHER INFORMATION <br />T+---------------------------- <br />0, PHONE # <br />R+------------- <br />PHONE # <br />I#I,III,I <br />TANK IDji!T S E CH ICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />3 39- _ <br />A 39- <br />N 39- ; <br />K 39- <br />39- <br />39- <br />+--- <br />P <br />L APPROVED _,KAPPROVEPk TH CONDITION(S) DISAPPROVED <br />A : ATTA NT WITH CONDITIONS) <br />N ; PLAN REVIEWERS NAME DATE <br />APPLICANT MUST PERFORM ALL WORKACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIRONMENT I�jEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMAN Rk FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />BECOME SUBJECT TOftF <br />MP S AWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING. "I CER T PERFORM THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSAF C FORNIA."j����,�_� -CCAPPLICANT'S SIGNATITLES LX/-`i�ATE <br />*------------------------------------------------------------------------------------------------------------------------* <br />BILLING INFORMATION: <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 />ameL <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />Address ,amu 4r -R467-- Phone ##ZOq- ;?-- <br />1 <br />