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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: iTANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT --------------------- _______ { I EPA SITE # -CONT------TELE-------- --------------- I PROJECT CONTACT & TELEPHONE # -+ I+----------------------- - ------------------ -------- 1 -- ------------ - - --------- -- -------- I F I FACILITY NAME -------------------------------I iA ------------------'-`--- ---"x-^=-----/___f_/_ i PHONE # { C I ADDRESS ----------- 1 { L I CROSS STREET /' I I --------------------------�!_�✓,L% -------- T I OWNER/OPERATO ----------------------------------------------------------------1 _ 1 ------- - -- { C I CONTRACTOR NAME ��.) I PHONE # I O +---------------111�� - - —T1�0 f1ern---"- 7- �lN�—'�!_A- r�1�_c_----------------------- N - `%I I CONTRACTOR ADDRESS ----------- ----- ------------- ---I I T +---�--------------- - --- g5 7f,3I CA LIC # I CLASS // -------------- ---------- _7G693�-------- --------....... - - R I INSURER �� ,(�� ST I { WORK.COMP.# I I A I --------------------------------- C-- , _ 1fa��---- tS 30 _ Zzz _1 ---- ---+------- - - I I OTHER INFORMATION I { T +--------------------- I - ------------------------------------------------+---- -------------------------i I PHONE ----------------------------------------------------- t I I PHONE # IIIII{{111111--- --- ------- - ---------------- TANK IDIg- - ' -------------- I TANK SIZE I CHEMICALS STOR CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I 39- I v �•� Oo o f S T I 39- 2 I I Icy A I 39 a J s- I N 1 39 I I I o -Tey { I K 139- 39- 39--1 9-39-39-I I I { *---II{I{ 111{111 II{II{IIIIIII{IIIIIIIII{II{II{11111 III{IIIIIIIIIIIIIII{II {IIIIIIIIII{III{ II 1 11 I 1 { P I ILII{IIIIIIIIIII{IIIIIIIIIIIIIIII L I APPROV APPROVED WIAH CONDITIONS) DISAPPROVED I A{ 011 E A ACHMENT H CONDITIONS) I N I PLAN REVIEWERS NAMEDATE O +---IIIIIIIIIIIIIIIIIiIIIIi{i i{{I{II II II I{{{I 11 {III{1111 {III Illllllllli{Illili{illi{111111{I{I I III{i 111111{lili{li{{ I i APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY { 1 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 I { 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 I WORKER'S COMPENSATION LAWS OF CALIFORNIA." { { I APPLICANT'S SIGNATURE/I I TITLE �T DATE -----------------------------------------1 ___________________________________________ --------____-__} 1 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 must acknowledge this responsibility for the billing by signature and date below. Name i►/AA k- &A �/,� Address_4?/ 2_f�j, zalzea Phone # 2at-�sL-33�o Signature, c: 4�0-� EH230038 1 5 �� cam- / 1_�V 614__ (revised 1/31/02) J 1