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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3P0 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 />-X-TANK RETROFIT _PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+--------------------------------------------------------------------------------------------------------------------------------+ <br />' ; EPA SITE # 1 PROJECT CONTACT 6 TELEPHONE # <br />F ; FACILITY NAME PHONE <br />C ; ADDRESS �, C' � L` ' <br />I +---------- '---------i�frc E-�`''`----€-�"��`------ S� 6------------------------------------------------------- <br />L CROSS STREET <br />Sf m -Sir ------------------------------------------------------------------------------------------------ <br />' <br />, <br />T OWNER/OPERATOR` ' PHONE # <br />Y Le5cwo Co ' <br />cvc� i'_ I <br />1 C I CONTRACTOR NAME ive J_`t=�+� `�_� i� VYv�- `� ---------------------- -PHONE # � l.t �4 J ` ` c X------' <br />IO ------------------------------ <br />I N I CONTRACTOR ADDRESS /_ k b _/';t`' C�kL_ &-4� --------------------CA-LIC-# �'�,5�-------____I-CLASS-- d�` �(�_ �-�'� <br />f T +----TRACTOR--------- v 1 ](�! -- -- . - <br />R INSURER �� , �� ` WORK.COMP.# <br />AI----------C------� �--T ---------------------------------------------------------------- <br />C l��ob3 7_l__ <br />OTHER INFORMATION ' <br />0 I PHONE # <br />, <br />, PHONE # <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 />+---.I.,1., , „ ,,,, I I II, „ II IIII,IIII,IIIIIIIIIIII „ II „ „ , <br />P I „ <br />L ' APPROVI APPROVED WITH CONDITIONS) DISAPPROVED <br />A E ATT HMENT WITH CONDITIONS) <br />I -N-PLAN REVIEWERS NAME - 11111,,,,,11111,11111111111111 „ DATEC_ <br />1(1,, 1111,1111 „ <br />APPLICANT MUST PERFORM L 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 SIGNATURE:/kU(LjL�,LL'�' 4� �V�-C-% �'LQ"�-'�''�'�-`' TITLES+% UL�(.��� DRCY DATE ` 3, W4 <br />, <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 />NameKjWaiU'-L 1UA'Q1kW Address( 96Ova u 17e S , LA gVI(D,Phone # 46 T- Wa-603' <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />