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0REC E V LSD SAN JOAQUIN COUNI'Y ENVIRONMENTAL HEALTH DEPARTMENT MAY 9 2006 304 3 OCKTON,CA95 02RD FLOOR ENVIRONMENT HEALTH APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT PERMIT/SERVICES THIS 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 REPAIR/RETROFIT +______________________________________ ______________________ ____________________________________________________ + I EPA SITE # : PROJECT CONTACT A TELEPHONE # +_______________________________________________ I______________________-__________________________________--'________/___________i 1 F I FACILITY NAME Conoco .-PMt i -4 a-7 eskl{ PHONE # '�j(J' 9- 1 A -----------------------------------------/-fir/-�-(-/----- - ( ` ----------- C � /� 1 I I ADDRESS 17 v/___G_ ,�/�?,tel lj� __'_^_�1d_`_'_'___ �'=�!Y_�_ I�LZ__�S ZI<__i__________________________________; r I }_________ _ __ _ _ 1 LI CROSS STREET i T 1 OWNER/OPERATOR 1 PHONE #� _ �� 1 i Y 1 C 1 CONTRACTOR NAME -- �� : PHONE # 1 O +____________________ ___ Ili/ N : CONTRACTOR ADDRESS rI ______ ______ ___CA LIC # �l�_-_�_�D______CLASS _____________________1 i � 1 R 1 INSURER �' -\ & 1 WORK.COMP.# L ; A1------- f anal L ------CC2------------------------------------+--------------3-/2_c�s=s----------I 1 C 1 OTHER INFORMATION i r 1 0 1 1 PHONE # , i 1 PHONE # +___1111111 L'I111111111 L' , � _ ________________________________________________________________________________ TANK ID # TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED 39- 1 T 1 39- 1 A 1 39- 1 N 1 39- 1 K 1 39- 39- 39- +-p L' J11111 ;11 111 L1111111 1111111111111 L'111111111 L'L'1111111111 L'1, „ „ 11 L'1I1111111,I;111111111 „ � „ 1 L1 /�A�PPROVED APPROVED WITH CONDITION(S) DISAPPROVED �]J I N i PLAN REVIEWERS NAME S E ATuT,A'C� WITH CONDITIONS) � DATE Q� '✓(") 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 CALIPORNIA." ®® 1 APPLICANT'S SIGNATURE: TITLE (0,a CD ///H//tG/L1 DATE 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 Phone # Signature EH230038 (revised 1/31/02) i