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u SAN JOAQUIN COUNTY E ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3R0 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 REPAIRIRETROFIT ----I-EPA SITE M................................I-PRQJECT WNTACT R TELEPJDNE M _j OL40 JA.C,-r -- 1354-1573 -3 "3+3 a_________________________________________________________________________________________________________________________ I F I FACILITY NAME Ll L;-(Lp M (�(�- I PNaNE A IA_____________________________________________________________________________________________________________________________I I C 1 ADDRzsS I rj 3 r- . IP "M5T. ?fI PC ( CTP. _ II +-------------------------------------------------------------------------`-------- I L I I CROSS STREET N p Rrj..f B F U- S ra ser I 1 I"--------------------------------------------------------------------------------------------------------------------------I T I OWNER/OPEMTOR PMM A IYI ULT'A4.4,4 ., r,79,w. 3rd sr.I �IanlFonfJ�GP ggq-5$3-32 I I-----------------------------------e_�__.__._.____.__'�_II.______..-.-__.._.._..__.___.....__,...__...___--------...._.------.........I I C I CCNIRAcroR NAME 'r0 1P- %>eTB(L.M INIii_-D I PRONE A 1 0______________________________________________________________________________________________________________________________I I N I caNTRACIOR ADDRESS I CA LIC N I CLASS iT..............................................................................................................................I I R INSURER I WORR.COMP.A AI_.______________________________________________________________________________________________________________1 C OTHER INFORMTIM T................_-.-_....._-._-_____________________...___...______._.._-..._________,_.-----...-...._.___._.._..___.._._..__.I O I 1 PHONE a I R----------------------------------..._-_.__.__.._____________.___________________________._______.__-.I I I PHONE A I 1---------------------------------"----------------"-------------"--------------------------i I TANK IDA 1 I TANK SIZE I CHEMICALS SIORED CURRSNTI.Y/PREVIOUSLY I DATE UST INSTALLED I 39- I �Q o 0 o I 8l C,A_Wafl DR CoASAI:ILIq UL1"OwrJ I T 39- �I 00 o RL �It.AOe OF %A3AL,Nq UNW-W0-JN I A 39- �I IO:o 00 89 �0.P.OF of �aso�ince} /JIJ I I IS 39- 1 I I K 39- 1 I 39- 1 I 39- 1 ---II I I II 11111111 Iitl l II I II I I ILII I I I III II III II I I I IIII11111I II II ILII I Intl ILII I II I I III ILII I IIIII I I II II I I I III II I I I III I III I I II I ILII II PI L I _ APPROVED APPROVED WITCO CONDITION(S) DISAPPROVED A I (SEE ATTACHMENT WIIN CONDITIONS) N PLAN REVIEWERS NAME UAM I """IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII1f1111111111111111111111111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII I APPLICANT MUST P®tPORM ALL WORK IN ACCORDANCE KITH SAN SOAWIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS OF I SAN JOAQUIN COUNTY, &NIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSU®, I SHALL NOT ENPWY ANY PERSON IN SUCH A MANNER AS M I BECOME SUBJECT TO WORKER'S WMPENSATION LAWS OF CALIFORNIA." CONMACTOR'S HIRING OR SUBWNTRACTING SIGNATURE CERTIFIES ME FOLLOWING, `I CERTIFY TMT IN THE PERFORMANCE OF TTP WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EWWY PERSONS SUBJECT TO CONPENMTION LAWS OF CALIFORNIA." I I I �WTyw�, APPLICANT'S SIGFATURE: TITLB Pyoj. C�'�� DATE 17 � I ------------------------------ Mho �fi.PQE(LJ 4--36yy-------------------------- 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. Jo Rtj VAUr u LT -A 47 An 0 S W NPKlrc Sr LP•G323a # 55�_5�3-3z3S-