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• SAN JOAQUIN COUNTY* S (- Ott � T <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3"°FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, R PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AR NDICATE PERMIT TYPE BELOW, <br /> _TANK RETROFIT_ _ (PING REPAIRIRETROFIT_UNDER DISPENSER__ _ <br /> CONTAINMENT REPAIRIRETROFIT_ <br /> --_-� EPA SITE #________ ____________ ________I PROJECT CONTACT S TELEPHONE # ______________ _____________ ___________________I <br /> +---------------------------------------------------------------------------------------------------------- -----I <br /> F I FACILITY NAME PHONE { <br /> A + M°-y /�J c �y--�`Ij----- - ----- �s�q) <br /> C ADDRESS �-0- --_�- ----__--'--- 4L y /__/_ <br /> I +______________ J _[pp____ ______________________-_______________-________________________I <br /> L CROSS STREET L /�__ /� — _ ________________________________________________ <br /> L +_CROS_________________!_ _ ________ <br /> T 1 /OPERATOR (fie 55 N a 7'2aC-- <br /> PHONE # I <br /> I Y , SO-e=---1'� ` !e ----------------- -9-- - Ge_-- -_-- -----i <br /> C I CONTRACTOR NAME - I PHONE # o <br /> � T ` <br /> O + - ----- ---- -------------------------------------------- <br /> N I CONTRACTOR ADDRESSe_ _w_aM__- _G LIC # GB6 a1[�__� ccnss�i_j _C=La [� <br /> T +___________________ <br /> R I INSURER I ----------- ----7 { <br /> A I------------ 7 " T- F _�[ 7 2 i 18 ------- <br /> C I <br /> { OTHER INFORMATION ___________________________________________+_ I <br /> { T +____________________________________ _________________________________ _ <br /> { O PxoNE-#------------------------------I <br /> 111111{Illllllllllilllllllllllll____________ ____________________________________ __ <br /> TANK ID # I TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I <br /> I 39- I 1 I <br /> T 1 39- <br /> A 1 39- <br /> I I <br /> N ; 39- <br /> I K 1 39- <br /> 39-_ <br /> 9-39- I <br /> +---III 1111{1{111111111 IIiIIIIIIIII{lllltllllll' Iii1111 IIIIIIIIIII111111111111 III I1111, IIH IIII IIII111111 1111 ill11111{1 <br /> L I APPRO PROVED WITH CONDITION( DISAPPROVED I <br /> A I IS ACNMENT WITH CONDITIONS) DATE <br /> I N I PLAN REVIEWERS NAME ; ill {,i„111 <br /> + IIIIIIIIIIillllllllllillllllll IIIIIIIII I IIIIIII1111{111111ii1111i1111IIIIIIIIIII{1111 111 II I , " <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF i <br /> I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNERNEROROR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY i <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL HOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO <br /> I WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> i <br /> 1 <br /> I APPLICANT'Ss <br /> IGNATURE: 2C TITLE R�/t S M L /r - DATE <br /> I J� { <br /> +___________________ _____________ _ __________________________-______-______________________-______________,_______- <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 /> Name Address 3 s— Phone j(; 3V <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> i <br />