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SAN JOAQUIN COUNTY R80 ENVIRONMENTAL HEALTH DEPARTMENT _ 304 E WEBER AVE,3RD FLOOR I-F ✓' 2006 STOCKTON,CA 95202 U APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT ENVIRONMENT THIS PERMIT ExPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PE�M71°TV®E'BELOWES _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ------------------------------------------------------------------ 1 EPA SITE k PROJECT CONTACT & TELEPHONE # +____________________________ah_._s_.________G__o______1N________/1__________________________________________________________________- 1,4 1 A + FACILITY NAME u,----rg'L•Y__"___ ________PX ONE-N L09 '_*3 Z— I.+ ADDRESS --' ZYa ----C ___ 9s37�e L CROSS STREET I _______________________________________________________________________________ ' _______________________________________ T OWNER/OPERATOR , Y PHONE # v ---C ; CONTRACTOR NAMEG ------------ Q PHONE 9 --------------------------------------- --------------------------------- ; N CONTRACTOR ADDRESS ��- Q-. __ /�_ !_r�-�_ I =-L J$ZVV_-CA LIC-p-� �y 2 J / v f_ CLABS T +___SURE____________ / lam- -Wl`� TI _ WK .1 L f7 ______________________� R INSURER F� 6 WORK COMP.# - ' C ; OTHER INFORMATION +-----�----- - ; PHONE # R +____________________________________________________________________________________ __________________________________________________ :_PHONE_# 111'f� " ; TANK SIZE , TANK ID # CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T 39- A 39- td 39- K 39- 39- 39- I P L '1111 „" 111 APPROVED 11 APPROVED WITH CONDITION(S) A DISAPPROVED ^ /' (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME IIv. Nf� DATE Z' C. J`Ob , ,,,„,r„ 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 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 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE TITLE ✓' ' 'K DATE--------------------------------------------------------------------------------------------------- f ------------------------------- 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. Name Address Phone # Signature EH230038 (revised 1/31/02) 1