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11/10/2005 _ 13: 11 464013: ENVIRONMENTAL HTH PAGE 02 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,340 FLOOR STOCKTON,CA 09202 APPLICATION FOR UNDEROROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WHITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: _TANK RETROFIT )_PIPING REPAIR)RETROFIT ,UNDERDISPENSER CONTAINMENT REPAIRIRETROFIT __________________________.......-____........___._..--_-_____-.-...__-_-_--....____._....--._-__--...._-______-_-------........... I EPA sin F •'- 1 PROJACT.CONTACT 6 TELEPHONE M �________________�ry _ ____•....__.___.. _____......................---------.-------------................... I p 1 FACILITY NAM6 PHONEY r I A. i AO............UC..... #�3((- ...---- .....................................................�------... a�:�{ �.:.�J: 7 .-----1 I .... -- -- S3 // — 5 rrc Cr 1.5.32 ?...--------- L.:..._--- - L - 7 T.. -------- - ....... 1 CROSSSTREET I ....... _............_______________-----------_-------------------------------------------_______------------------•_-_._---. 1 T I OKNER/OPERATOR ),NONE Y I va I"✓o �;��_ - 5S9- 5�3 32.9b' C I CONTRACTOR NAME .F I PHONE R / ------------------------rI -- Con _..-..c , atil ------ .......................................................... ...........1 0 ------------------T-=•-----------..� :_'----------------•---•----•-••-----....•----- --- -q----- .. ......----I N CONTRACTOR ADGREB6 ••TT,5(pO <<O U �L (wL I CA LSC R &Cf 3g0'7 I CLAEa /' I-IIA 13 IZ T ______......___------P.-..______.G..` .:S�__�....____ ... __.__....--_---_..------____RC .....--__-.._-_---*-------____I R 1 'REOPEN �_A4-�, CFJ yi'I Tr CJS FJiJ Y7 •I HOA!(.COMP.M )ry�-I 'OJ I I A I............... •p •-- - ---------- ------------------------ ---... -----.. ---------------1 I C I ORISE INFORMATION I I T ________________________________________ ___________________________________________________________________-/-�-.___-.---.....1 1 0 1 1 PHONE A 55q- y�..0833---------' 1 R ...................................................................................................... ....... I I I PHONE.R ' ___IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII••..............................._----------------------- _-_-....._____-..........._._.._1 I TANK ID 9 TANK ST26 1 CHEMICALS STORED CURR3NTLY/PREVIOUSLY I DAY& USS INSTALLED 1 139- I i T 1 39- 39- K 9- 39-K 1 39- 139 I I I 1•�11111 11)11 I III 111 IIIA I I III III TTrlli II I I I I )III III 111111 Illi L I APPROVED APPROVED WITH CONDITION(S) _- DISAPPROVED I AI app SEE ATTACHMENT WITH CONDITIONS) I N I PLM) REVISWMII NAME lj'IV Ia DATE 1 +•••III11111 N II111111111111111 111111 Illllli 111111 I I )III IIII�Tfflllllll 111 II IIIIIIII APPLICANT MUST PERPOAM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUINTHE COUNTY, EfW SOF THE NPALTH WHICH MINT. OW970. OR SGUM,LICENSEDI AGENT'S SIGNATURE CERTIFIES THE FOLLOWING; -I CERTIFY I THAT IM THE PERFORMANCE OF TK6 EV9A FOR RHICH 'MIS PERMIT IS ISEDEO, I SHALL NOT FOR SU ANY ACTT IN SOAR A MANNER AS TO BECOME SUBJECS TO WORKS'G IN MR IAMB OF CALIFORNIA.'MEWORK CONTRACTOR'S HIRING O0. SUED, I'R SMALL EMPLOSIGNAY PER CERTIFIES SUBJE THE IPOLLONINC, •I C6RTt PY THAT IN 'INE PEAfOPMAHCE OF TH6 NORM FOR WICK THIS PERMIT I6 T99VE0, I SHALL EMPLOY PLRSONS SUBJECT TO 1 NORAER'S COMPENSATION LAWS OF IPOANIA.• i I I APPLICANT ✓ I-I'_ TS[LE . �-eV-'C/ Uu4`P.I 1 DATE Z' 7 BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit paymerr coverage per lank. If the party designated below is different than the permit applicant, e.g. propeM owner, the of rty must acknowledge this responsibility for the billing by signature and date below. Name rl �,� on/ST/i�Tio A dress 2'� a Sd✓aau� Avg S•C - Phone # $31-`lisv Signatur WN' eo- - a �W EH230038 (revised 1/31102)