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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 361 E WEBER AVE, 3f° FLOOR STOCKTON, CA 95292 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 _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT __ ----. .___. __.__ _ ___ 'jY __p9 BPA SITE p C.AR d(x7 I-4-� �34q PROJECT CONTACT I TELEPHONE ��4_F 1�AnL.I-ds __CP"" ------------------------------------/�3 J P FACILITY NAME USq-1'_/1s -� I'0 ____ ____ PHONE p'a__ X54 ADDHHEB 2La--riF��a_54,_4kio►L,C}F�------------------- CROSS STREET I______________________________________________________________________________________________________________ 1' ------ PBRA R -- .-- h __________________ PHONE p T * CONSRACTOR NANeI • >ti�-�__�3'/n��I'n _ y._ 1___f4� PHONE p O�f �i O, b„_L______� O------------------_ _Q'-Y----�,([-Jj�j t- c-y-�1-1--------- 1�'7 -( N CONTRACTOR ADORBSS_� _ _ 'p' •UQ•` Orl �IIT�t� LIC p y _CLA8S �+T] F AZ} IG ___ 'T V- `-- - RA _INBDRER_ 4__ Fl h --------------------------- NORR-COMP-p_Is-1_I/a�-aVV (---- C OTNEt INFORMATION ----- -- t-------------------------------------------------------------- ------------`--- O I PHONE p R__________- -_ _____________t____________________________--__--_--___; PHONE p ... p .,.. ��.... ________________ TANG ID TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY GATE UST INR?ALL® I 39- T 39- A 39- N 39- K 39- 39- 39 P A N PLAN REVIEWERS NAM APPROVED APPROVED WITH CONDTTTON(S) _ _ DISAPPROVED (SEE ATTACHMENT WITH CONDITIONS) DATE Fil APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAMS. AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, RWVIRONMBNTAL HEALTH DEPARTMENT. OWNER ON TEAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS _ICSNSND AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS O�F CALIFORNIA APPLICANT'S SIG3N•TURB: l 1 v,/M1� �Mt+l�/--t1� tITLE /•M2tS DATE _______________________ _ - --- _____--------------------------------- ________-------_-_-____-------------------------------- 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. kj-,rA �oIY�tQ(prpac14tgI) G� P)anchQ ne 3 !1 8. Name C-0'4 h-hwL- Address lew�e*--kH 66113aC) Phone #X05 &lL/-ate EH230038 (revised 1/31/02)