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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3"D 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 ____PIPING REPAIR/RETROFIT __UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +---------------------------------------------------------------------------------------------------------------- - ------ I (,(/AcTo�i 9/b- EPA SITE # I PROJECT C�'=ACT a TELEPHONE # IAA .3 � 2 /� r L,� ____________________________________________------------------------------ ______________________ -__._. S , F I FACILITY NAME n v tV_ S To P & /3g PHONE # .____ __I_ ------------------ C Ii I ADDRESS � r S3 6 r A(C o L M 1J L V�-------------------------� 1------------------------------------------------------------------------------- , L 1 CROSS STREET II+-----------------------------------------------------------------------------------------------------------------------------i T ; OWNER/OPERATORI PHONE # I Y 1 OutZ ST-oP KAA-2IGF�rS I S -,o - 6 S,4- gsoo 1 I---+------------------�A----------------------------------------�--------------+---------------------------------------t I C I CONTRACTOR NAME L TK O 9 5 K r.1 E E 21 /,c l ,- -- "` C-:----- -- � PHONE - 1 0+ ------------------------jam: o:-- 0;C ---i o z t,;--------------- 1 N I CONTRACTOR ADDRESS� f► AGO_E?____I_.7_b9 (___I CA LIC -# 6 (�, Z3 r I CLASS A, 8 4 A IT ------------------------------------------------.__ _-_ _._._ _ --__ _ ______._ ------_!__--_-____-_____ 1 R I INSURER S T A -TE � �% MC � I WORK. COMP. # �' 3 f� C Z �. " 0 3- - � +---------- ----' -----'^-- 1 I C I OTHER INFORMATION ---------- 1 1 PHONE # I D I 1 ----------------------------- ------------------------------- 1 1 I PHONE It 1 -IIIIIIIIIIIIIIIIIIIIIIIIIIilllll-------------------------------------------------------------------------------------------I I TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED 1 1 39- 01 I lO,000 1 GA-Socl�c� — 8} I U I T 139_ Cj?�I /O, 004 I (ZA.SOGIMIE, tl A ; 39- 03 1 $, 000 I r: A -S0 LI MA, L) #44C 1 i N i 39- 1 K 1 39- 39- 39- P 9- I I 1 1 139- I I 139- I I 1 I _._Illllllllllllllllllllllllllllllllllllllllllllllllllllllllifllllllllllllllltllllillllllllllllllllllllllllllllllllllllllllllllill i IPI 1 I I L i APPROVED APPROVED WITH CONDITION (S) DISAPPROVED I A I (SEE ATTACHMENT WITH CONDITIONS) 1 N 1 PLAN REVIEWERS NAME DATE +_._IIIIIilllllllllllllillllllllllllllllllllllllllllllllllillllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll I 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRC>*0=AL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 I PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I 1 BECOME SUBJECT TO.WORKER'S CX7MPENSATION LAWS OF CALIFORNIA,- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO COMPENSATION LAWS OF CALIFORNIA." I i I r I APPLICANT'S SIGNATURE: TITLE �rZ t I F..►�'" DATE �iglCbl_A!�C:- w----- ---- c.Tp.l--------------------------------------------------------+ BILLING INFORMATION: THAT IN THE WORKER'S 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. P.o, T�;0x Name t eb+ Arc. WLL�� Address W _s �_ __fir& y,___Phone # 3 3 = <<s L _