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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: _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ----------------------------------------------- ----------------------------------------------------------------------------------+ j EPA SITE # ; PROJECT CONTACT & TELEPHONE # 1 1 +---------------------------------------------------------------------------- - — c_--_!�_v_u� c�j{{{/// r'G / - - - -/---I F i FACILITY NAME ; PHONE -# O (�'j) A+----------------- 7-7- --- ---------------------------------- ----------- C; ADDRESS 0. tl.�� V -C. /� 1 I +----------------------- �JJ 1 L ; CROSS STREET' •- 1 1 I +----------------------------- T j OWNER/OPERATOR ; PHONE # `-:---------------------- - 'h_ c-- + -----/{_a rpt � �_ �} ctr _C_� _fir!"7Qi ! �; o �) �So -2 G-4' -%--- ---------------- -- --- ---- C ; CONTRACTOR NAME /'— / -7-- ; PHONE # - - - _ _ - 0 +------------------------`-'- -� ----------------------------------------------------------------------------------- N ------------- ---- ---------------- ------------- --------------------------- 1 N 1 CONTRACTOR ADDRESS / 1 CA LIC # ; CLASS A /�1-- - =------L -------------- 1�--- � _-------------I-Tj C-� '�J�t 2I 1 T +-----------------�_ 2-9_-3 S ---- /_ tcj __ lL 77 1 - R ; INSURER C ! - `� e- F N rS ; WORK. COMP. 4 L ,q ' 1 A 1------- ✓ I ------------------------------------- 1 V O ----�-�-1----- --'--------------------------------------- 1 C ; OTHER INFORMATION T +------------------------------ ------------+--------- ------------------------------- O ; 1 PHONE # %� 1 R +----------------------------------------------------------- +-------- `-� `��- ` -��- ----_3 3 _ ------------------------ PHONE # 1 1111111 +-�-IIIIIII1:1I 11111H IM! IIHIM! I ----_------_ -------------------------------------"-----'----'------------------------- TANK 1i ID # ; TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED 1 39- T 39- A i 39- i ,zo bf-I 0iLL A7 Q I K 39_ i ��7 a -O D 39- 39- +---IIIIIIII11li I1111111IIIIII11111 P L ; A I N ; PLAN REVIEWERS NAME +111111111111iiil.111111I II11111111111�111111 IIIII IIII IIIIIIIII II 111111 IIIII I11111IIIIII11111111111111111111111111111111 11111111111111111 II11111111IIIIIIII IIIII III IIII III II II 111 111111111111111II IIIII11111I 1111 APPROVED APPROVED W CONDITION( DISAPPROVED 1 I E T ACHMENT CONDITIONS) DATE I 1 i•iii111�1ii1 liiiiiiiliii iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiili iiiiiiliiil111iiii j APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'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 AS TO 1 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA." 1 I 1 1 I I 1 _ I I 1 I 1 1 APPLICANT'S SIGNATURE: - z TITLE 'S'S '"�'W' DATE -3/-02 I I - �U +-------------------------- -------------------y ----------------------------------- BILLING INFOR TION: 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 Signature, Address 7- 5- 3S Wt 9 Lya 7vt Phone #(�09) `ice/-�33% EH230038 „ (revised 1/ 1/02) 1