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SAN JOA'QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,V FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THfS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: *TANK RETROFIT PIPING REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIPJRETROFIT --------------------- ------------------------------------------------ j �A� �-y-��i [� gyp. �}��) -------------------/-]-y}+� ! I EPA SITE #{.+y`�1.- QC)0;2&4Z��1 PROJECT CONTACT 6 TELEPHONE # 3'nN P,�TV��F/ y b;;D.77�- t;, j +__________________________________________________________________________________________________ _--___________ F I FACILITY NAMW i PHONE #T1zt) f 209. 599. ZII - - - _ y------- C I ADDRESS 1022 RzI9NTA0V QAC) I24PON, ",k95334 I +------------------------------------------------------------- --'---------------`-__--____-- L I CROSS STREET i - - - ------------------ ----- 1 T 1 OWNER/OPERATOR i Y iI PHONE # i ------------------------------------------------------------ I C "A"'NAME r�I' �nc�/ .lE �1 Ty�,��^ u+---"`----/-'-�-/-�--[-y---------------------- O +-------"----NAME TTEd4wLa ._eNgiN I G_� 1V�1 C"V S•i�ANs�1�jPHONE #- 051) J'� . i N 1 CONTRACTOR ADDRESS54 UNN i"ryENUe I 7�^`f Q.}�1. CLASS ___�_p_A_____________`___ CA LIC q ! .L 4 A 14AZ B 0�p T +---------` --------------------`-- R 1 INSURER �ATr T�rRJ __ _______________ _________ TV Iv� i WORK.GOMP,# Ip i..___________________________________________-____ v` ---------------------------------------- 1 C OTHER INFORMATION T +_________________________-_________________ 1 AN VP1 51 W Cor l-F-A N>/ \ INfN� �*ee 2_ 6- - --------- --I PHONE # 650. -/�2. � I I PHONE # (0 r7-0. _0 70 I III I -'II'III;lillllliilllllililllllli------------------------------------ -----____-- _ .' TANK ,4 1 TANK.SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY` DATE UST INSTALLED 1 39- QCj i T 39 I_ I 1 i A 39- i 1 N 39 K i 39- I I I 139- 139- I i ---IlillllllliilllllikillllliilllilfliiillllliilililllliifiillllllillIIIIIIItIIIiIIIIIIIIIIlIIIiIIIIIIIIIIIIIIliili1llfllllilillli IIPII L i APPROVED X APPROVED WITH CONDITION(S)) DISAPPROVED A c TTAC}itAE�l'T WITH CONDITIONS) J N 1 PLAN REVIEWERS NAME /f^� DATE --- i1;lilllililllililil(Il�iili 1911111iiiIIIVIiIIIkCIIIIIIIIIIIiIIIIIIIiiilllEili9lilliiillllliiflllllliiililllllllillllllplllli it APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 'i SAN JOA=N COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I. THAT IN TRE PERFCRMANCE OF THE WORK FOP 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 SURCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TD 1 I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I APPLICANT'S SIGNATURE: TITLE DATE I 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. Name_ -----_Address__ _-- _Shone # --____-- 1