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• or,� • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 31'D 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 h.PIPING REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT + ____ _____ _____________ ___ _ _ I__-_______________+ EPA SITE N PROUECT WNTACT 6 TRLEPRONE A 1 ------------------- F I F , FACILITY NAME �PIAIe$ - CI ADDRESS Jecd_ I----------"-'-'— -------:-------------"— L I CROSS STREEPp� y�y T ➢WNER/OPERATOR k -/Qe_ -4) � , YI - +-----------'----------------------- ----- I C I CONTRACLOR NANE 1 0 +___________________________________ ____________ I N I COMPACTOR ADDRESS ]A F �I IT +_____________________________111 /- _________ I R I INSURER A________________________________________. C OTHER INFORMATIw T----------------------------------------- 0 1 __ ___01 R+--------------------------- I 1 +---11111111111111111111111111111111--------- 1 TANK ID R 39- D�ng�Q ISS T 39- A 39- N 139- K 139- 39- 39- ___illllllllllllllllllllllllllllllllllllllll L APPROVED TANK I PHONE R ?31 fie5t ------------------------ ---------------------------------- I --------- -- ________________1-CA LIC _p___________________ I_�SS________________ _____________ _ _ ___________ I WORK.Co1P.8 ------ -------+------------------------------ I --------------- ---------------' I PHONE a -------------------------------------------------------------------- I FROM it CORRENTLY/PREVIOUSLY I DATE UST INMALLED 1 II,IIIIiilIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIH IIIIIIIIIIiIIIIIIIIIIIIIIIIII I _ APPROp_Vy/)E .Wp��WIM CONDITION(S) DISAPPROVED (SEE ATTAMNN'1' WITH CONDITIONS) N PLAN REVIEWERS NAME \01'N:1 PclY� / DATE ---Illllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllilllllllllllllllllllllllllllllllllllllllllllllllll APPLICANT MUM PERFORM ALL WORK IN ACCORDANCE WITH SAN SOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN "QUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SICd1AT1JRE CERTIFIES TRE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIM THIS PERMIT IS ISSUED, I SHALL NOT ENPWY ANY PERSON IN SUCH A MANNER AS TO BEWHE SNE.IECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUEWMRACIING SIGNATURE CERTIFIES THE FOIIOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBMa TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." - I I 1 I APPLxcAxr's sx¢uxuRE: �� TxTLe x^®41 HATE O /O e 1 +___________________________________ ____________________________ __ -+ 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 6� �� lAddress ��a� �a 1-/0� Phone # r t� 3/-2�f If 13 GN,d-4:,no e lC dWge Ar S! -?J 4e