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0 �2 co�{S oTl SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3RD 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 REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +--------- ----- --------PROJECT CONTACT & TELEPHONE-#- -- --------------------`---Q-- -----+ EPA SITE # (CFAs, L WaL-re A ( 3-+-3--f1Si' +--------------------------------------------- ----- F FACILITY NAME---Co 1.(.GCo_PN'_( L L,PS---*-Z_�_0_U v �- i----- ----PHONE-#-Z o g- -��' _ O 7 1 A +-------------- C ; ADDRESS g 6 0 6 -�.'•I 1.O a A-ro lam( - , , Ff I +--------------------------------------------- --------------------------------------------------------------------------- L 1 CROSS STREET I q v(s R1, - I ---------------------------- ------------------------------------------------------------------------------------------------- T OWNER/OPERATOR C 0-I 0 C 0 'P (L.�• (Q s PHONE # Y 91 f ---+------------------------------------------------- -------------------+---------------------------------------I C CONTRACTOR NAME - PHONE # LAV p Lt.n rL Cilµ (�(z 1 K C�--�- ---�=--------------------------- -6--- 3---/(S z------ N CONTRACTOR ADDRESS 1'.0 B 0 X I o z Ste- W, S A-c.fi0 C•A 1 CALIC # 6 ( �2 3 v- 4 ,_ 042- T A•Z--- CLASS T +------------------- ------------------ ------ --------------------------------------------------- WORK.COMP.# 9.(3 coot( qz }a 5- 5;R INSURERT DrJC"E--- t> ------------------------MAD -------+----- C I OTHER INFORMATION ------------+---------------------------------------I 0 ' PHONE # ------------------------+----------------------------------------I IR +------------------------------------------------------------ PHONE # -------------------------------------------------------------------------- -- SII " I �ITANK ID #I TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T 39- A 39- N 39- K 39- 39- 39- P L AAPPR VE APPROVED WITH CONDITION(S) DISAPPROVED A A/1`,� (SEE ATTACHMENT WITH CONDITIONS) y ^_ N I PLAN REVIEWERS NAME f/IY'` -10 DATE lJ 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 CALIFORNIA." ODATE APPLICANT'S SIGNATURE: TITLE l I(LT_2 D'CJr>DPL +-------—------------------------------------------------------------------------------------------—----------------------------+ (Y1 y,�ara�'�s ftp l�d - iLr�- �,•v{-�s BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit paymen coverage per tank. If the party designated below is different than the permit applicant, e.g. propert,. owner, the party must acknowledge this responsibility for the billing by signature and date below. Name G__j.&j.4 �E,i�K�. Kc Address f.b,30)( IoLr (Al, 5:A4-1-0 Phone # 74 - ;3y3 -87 �' a 9sb q/ Signature toe LAX EH230038 IS ��(� • �'`"'' (revised 1/31/02)