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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3qD 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 REPAIRIRETROFITUNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +--------------------------------------------------------------- ------------------- `---- - p- EPA SITE # I PROJECT CONTACT & TELEPHONE # 5 c)h cj 6 y `kS t' 6 k - o / a -------- ---------- ------------ --------------------------Tk ----�------ ----------------------------- P ---- -_ _ --_ - ----- — --I F FACILITY NAMBO �0 �� G0��5 PHONE # a 1 A +-FACILITY NA - ---111111 �/�-L��{�" - - q------- ----------------------------------------- L: --HONE-- a- �3_ ------- C ADDRESS _lgfl _lC'Gti1� _a.l__��1=��-j-____1515 _ L I CROSS S JTRSBT + --------Lex�O ------_ ---------------------------------._---__-_-----_-__-_----_-_--__---- /OPERATO T OWNERPHONE # _1 31 ------------------y+-------------------2a_ PHONE CONTRACTOR '# 950 +_----- -------------------- _6$--1- N l 8----------- -; ; CONTRACTOR ADDRESS ." L CA LIC # CLASS T +------------------- `-- 52 _ C__��.1 — ----� - -1---- -----� s33 ----'------- _- - a ------- i R ; INSURER C ; WORK.COMP.# O 6 19 C OTHER INFORMATION -------------------- / A�- =_ic� e�__ _ 4 aSa�_ ___ _ _ _ _ __ _ __ _ _ 1� 3 p ` `--------------------------------------------+-------------- ---- —------------ ---- i R +----------------------^--------- � � PHONE # � •• ________________________ __ ______________ a � 5b�_ >;,t TANK ID #„,,,T TANS SIZE ; CHEMICALS STORED Y PREVIOUSLY DATE UST INSTALLED 39- Q�� ?�Q � �. T 39- I-�.�100 ID 1 A 39- N 39- K ; 39- 39- 39- +---;.1 .....................................1..., 1;111,;;;;.;;;; ; 11 11;1..,.,.,.,. P I L APPROVED ✓ APPROVED WITH CONDITION(S), DISAPPROVED A( BE ATTACHMENT WITH CONDITIONS) N ; PLAN REVIEWERS NAME 6A?1 (�tiG�S HATE L.)Oi�06 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGBNT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A3 TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THATI PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS CAL FORNIA." APPLICANT'S SIGNATURE.- t�(.! TITLE r C✓� _� DATE , +-------------------------- -------- ------------------------------------------------------------------------------------------+ 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 musla,90owledge this responsibility for the billing by signature and date below. EH230038 (revised 1/31/02) #