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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 APIPING REPAI ETROFI ___UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT *---------------------------------------------------------------------------------------------------------------------------------+ EPA SITE # 1 PROJECT CONTACT 6 TELEPHONE # ---------©-----'�u>s t ---_9 -_S3 r �l ►3 F I FACILITY NAME PHONE # A --------------------- ---________________________________-____ I - -------------- ------------1_Y__'___�s>`fid ` _ _o' t L ; CROSS STREET F1�• ---------� -fi T OWNER/OPERATOR PHONE # Y ! ��i ---------------------------------------------------------I �U�/-5'7�- 7/�- - - +- -- C ; CONTRACTOR NAME .� PHONE --------� -- - 5- ��-' y= �Y'i .�s�rt` Sly rrSSt--c-,--1-PHONE 4---------------------------- N t 0 ------------------ - - CONTRACTOR ADDRESS (,{�, J"S�" CA LIC # CLASS F( p.�J / T _____________________- 4_v___�y,�� 1__lL _I__________ I+__]�4_J_____-_ ___ ` 1 WORK.COMP.# RA INSURER__________51IC-J_!_L_1�= '_________________________________________ / J i i C OTHER INFORMATION i i 0 ; PHONE # PHONE # - - l----------------------------- __-_- __--_-_____--_-f-------___- ___----I---______- - --i TANK ID # TANK SIZE i CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T ; 39- A ''I 39- f N , 39- K ! 39- 1 39- 39- +---� III X1111 I11111111111IIIIIIIIII11111II III11 I1111111111111111IIIIIIIIIIII IIII111111111111111111111111111111111111 1111111 III�I P L APPR APPROVED WITH CONDITION(S) DISAPPROVED A i (S CHMEMTf WITH CONDITIONS) N PLAN REVIEWERS NAME DATE I i ii iii ii ii i i i i i I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AMID RULES AND REGULATIONS OF 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 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 SHALT, EMPLOY PERSONS SUBJECT TO i i WORKER'S COMI-ENSATION LAWS OF CALIFORNIA." I � I � i � I pC J¢ y APPLICANT'S SIGNATURE: A/� � TITLE DATE i +-------------------------------------------------------------------------------------- -----------+ 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 must acknowledge this responsibility for the billing by signature and date below. Se ru 3 . S hJ---. Name T Address Phone# ,j)E -53 - � 3 1