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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3a'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 _PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT I EPA SITE If I PROJECT CONTACT & TELEPHONE # I -___________ ____ _ _______________________________________________________ _____ I F I FACILITY NAME ---___PHONE_#_',__ ____ _ ____ _______ ------------------- ------------ 1 I A ---------------------F1---y-�--/-Q---•------------- - opyV _-_928-2 C ADDRESS �132___!!_L FLLS� � P___C! _.______ � !_Y'_` _______________ L!G+ _________1 I ,____________ I L I CROSS SIR= I ,_____________________________________________________________________________________________________________________________I T OWNER/OPERATOR II ls/aPHONE Y 'u + --------- --- --------- wau -e - --------- --------- c CONTRACTOR NAME T_- � Pxoxe # �p9 CJ I0 --------------------------------`` --L'-�-- ------5`-- ,-- C'"------------ N I CONTRACTOR ADDRESS I CA LIC # CLASS T i_____________ ¢___Ls� ___ 1sn2�.cJvt22_ ;,________________ -__________G'r,/__f}__1�z�zM�hr I A I INSURER __________________________________________s WORK_CO---- I A I_________STT ____ ! ,_______ I C I OTHER INFORMATION ____________________________I T ,___________________________________________________________________________________,________________________________________j 1 0 1 I PHONE # I IR *-------- ------------------------------------------------------------------------------------------------------------------- I I I PHONE # •---IIIIIIIIIIIIIIIIII L'IlIl111tllll---------------------------------------------------------------------------------------------I I I TW ID # TANK SIZE I CHEMICALS STORMENTLY/PREVIOUSLY I DATE UST INSTALLED 39-_ Z I i I T 139-- /dLlf..i� I N 139- G i i i K l 39- 39- 39- + 9-39- I ---11111 1111111 III IIIII IIIIII III 11f, IIIIIIIIIIIIIIIIIIIII II II IIIIIIIIIIII I IIIIII IIII III II III 111111111111111 iP L i APPROVED APPROVED WITH CONDITION(S) DISAPPROVED I A I (SEE TACHMENT WITH CONDITIONS) I I AME }}}"'fififi N PLAN REVIEWERS N DATE ---111111 L'IIIIIIIIIIIIIIIIIIIII IIIIIIITIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII L' I I L'II111r1��11II�f171IL'L'IIIIIII I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: ^I CERTIFY I 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 I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I WORKER'S COMPENSATION LAWS OF CALIFORNIA.- APPLICANT'S SIGNATURE: /^ i TITLEf:y', ,)t/�11-IdSNGir, re Ii 'SO-a3P 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-5/5,AuJs/Ryl,,j,— Qr Address 116 t,-' Phone #X05 Signature EH230038 (revised 1/31/02) 1