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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"O FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT.OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW <br /> EPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> TANK RETROFIT _PIPINGR ------ -_--- <br /> ____--- <br /> ' 1 EPA SITE pt�L--------------------------- PROJECT CONTACT S TELEPHONE a AJ go,,dE1J 916 <br /> F 1-Etxr«► "3zt9o=------ - ------ ----------- ------------------- <br /> A 95z PHONE p <br /> •---__-__-- Q <br /> I FACILITY NAME - ._� <br /> •_____________________ ------ .�p Q�u <br /> C I ADDRESS 'O(��p ftZDA1TA(w�i J1 !_r___ _____________________________ <br /> 4943.5,-R. __-_--99-- , ' <br /> t <br /> L I CROSS STREET NEAR hP(Ij FA+�D-�.Sy,,,�G <br /> PHONE 4 <br /> _ ♦-OWNER_____________ �+ - __ - _t_ _ F PHONE p —S 4-Z9-'94t,(6 _ <br /> i T OWNEAfYPBR1l3lR' ---T--- �-- <br /> r tN/rJ�JO- Z'_ t EYEIJ ItJG.---------- <br /> s _ -- - -HONE <br /> C CONTRACTOR NAME MlT rtJGtNktN4-€ Co1JS'ItlGiloN- I4G----------------------..b�(-7Z1.-41.Zo- -- <br /> O ----------------- cl. LIC a �Y339b------, CLAss /4 HkZ Gt0 <br /> N t CONTRACTOR ADDRESS tOSt oPPFWe-3.1mDM�AY 4�aebNli�OEa 9TH- -----'-- ------- `- --t---- -1- - --- <br /> T •_--SURE____ ___ - WORK.COMP.a 1554593 -c1 .__.- <br /> R INSURER INbq.+ �JN ------------------ <br /> c r- <br /> 1 C i OTHER INFORMATION __ -.-.__.--__.__-___................ ............ <br /> I T --------------------------------------- __ I PHONE q <br /> t0 I .....-. _ <br /> R ,.______-_-___.__---_----__---_.__-__ — <br /> __. _____________________________ <br /> ----------- --------- <br /> i <br /> 1 PHONE q <br /> ilitllliltlTIIKIIpllii111111111 'I___________________________________EMI-___.._OR__----WORT_---__-SL_-__.-_-_.-----__--- ----- <br /> CHEMICALS <br /> LEG <br /> 3N 4q TANK SIZE CH CALS STORED CURRENTLY/PREY IOU Y ogre UST INSTAL <br /> 39- 'fAoSOL Y /ogtwo 4Ar- UIJLBh Dr'D I I'd N '' <br /> �IN1.fAt7cD -ASe�g�t w <br /> ' T 39 'I <br /> A 1 39- <br /> N 1 39- <br /> I K 1 39- <br /> i l9- <br /> I <br /> --11lIIlIIlt11 IIItI111 L� � � �l1I1111111t11111 . <br /> • PAPPROVED APPROVED WItH CONDITION(51`" DISAPPROVED <br /> L <br /> A Ef ATTAQ}LM WZTH CONDITIONS) <br /> DATE1 <br /> NI PLAN REVIEWERS NAME <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGUI,AT IONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: ., 'I CERTIFY <br /> 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 <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACCOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE •/ /VI� DATE V310 2— <br /> - -- - - ----------- ----tLr'/1__trN_li �_COA/STie�- /AJG --------- -- ------ - - <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Named1r'ANG $ 4WSrA /NGAddress 106 &OMw660 IW So/rK4 Phone # <br /> oc6ilwSlbet cA 92054 <br /> Signature <br /> (71,�- , bus �# C zoq) Lf�b8 �$ ��-I..d..Pc <br /> EH230038 (h t B+VJ �z �T►�� �+$ww2.� U� <br /> (revised 1/31/02k,% ��v� 'fig �t �.c G.�ay,�� I(g�icR n r~Ql� t �--v - �'°'S <br />