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` �Al �0-1 fklUfx&l6ltlkTi Ila <br />ENVIRONMENTAL HEALTH DEPARTMENJ <br />304 E WEBER AVE, 3RD 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- <br />----TANK RETROFIT —PIPING REPAIR/RETROFIT & UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT <br />-------------------------------------------------------------------------------------------- --------------------------------------- <br />EPA SITE # PROJECT CONTACT & TELEPHONE # <br />---------------------------------------------------------------------------- <br />L <br />F ! FACILITY NAME i PHONE # <br />A------------------- p-l-bo-VAL --- blla� ---------------------------------------------------- --- --- q-- -�­--M,5§� -------- <br />C: ADDRESS <br />:I +------------------------- - u^ ---v---- -&-A-ek ------- %NQ ----------------------------------- <br />L 1 CROSS STREET <br />I------------------------------------------------------------------------------------------------------------------------------ <br />1 T : OWNER/OPERATOR <br />PHONE # <br />Y ----------------------- v --- 9--q iQ ------ <br />& ... . ........ ... <br />------------------- ---- ------------ Il <br />ll�:4 <br />ME <br />C : CONTRACTOR NAME --j - --- _PHO # U <br />0 ----------------- --- --------- - ----- ------- <br />%j LAS <br />N : CONTRACTOR ADDRESS_ LIC_#____'A 3 sq ... i_c S--3-x2D4Q--- <br />T+--------------------- to -Q ---- - ----- ------- <br />1 R INSURER :WORK.COMP '*V <br />"4 Sf �N`--------------------+-------------- <br />1 A ------- E) -v4 -k&-- �­4 --- ---- I J-01mg-c <br />i C I OTHER INFORMATION <br />T - _4 <br />------------------- J el )&c --- &-f ---- --------------------------------------------------- <br />0 i : PHONE #qq, <br />R -------------------------------- ------------------- -------------------_-_ --- <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 />1 K 39- <br />39- <br />39- <br />I P <br />1 <br />APPROVED L APPROVED WITH CONDITION(S) DISAPPROVED <br />: A (SHE ATTACHMENT WITH CONDITIONS) <br />1 N PLAN. REVIEWERS NAME DATE <br />............. ............... <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 SIGNATURE TITLaDATE <br />------------------------ ----------------------------------------------------------------------- ------------------------------ <br />0 0 <br />I- I I 10 - MOM <br />a IL <br />'lame <br />Address— Phone # <br />Signature <br />0 of ; <br />[g=$sFx I <br />0 <br />