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x -�a©q) �" yby-tJl� 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 REPAIRIRETROFIT -___-_--___ ___ _ _____________________________________________________y I I BPA SITE # I PROSECT cowA « TE[SPHONE « I C t '------------------------- -----------------`-------------------------�------------------------------------------ I F I FACILITY NAI@ vei\ �I Frets # is 1 A '--------- , --------------------------------�°"�1 - ``� 443-493 t I C I A EF39 -- - I I *-------------930 £as{__icor----�gcQ ��a CVS 1 I L I cross srREST - r-------------------------------------------------------------------I II ' ------------------------------ -------I I T I OWNER/OPERATOR I eloWts « I y 1vaNty ` Q.�.�k4� � S ` � gy---SYlz- ---a----- _ --�-- ------ ---- _ ----------------------- ci aeME -P--- 0P♦<Kf^^---- M.ww� .. wC_ «nw I eHONe « (�3J�_$TP-G83 - ---- ------------------ - ----------y------I I N 1 curr 1"'A ""' eX -7110j I cA LIc # ( j . I cuss I I R I INSOREE I Wom.comF.« I AI___________________________________________________________________________________a__________________________________-_____I I C I omEN INFOPNATION I I Ta ______________________________________________________________a -________-____--_____________I I01 1 Fmom # I R . ________________________________________________________________a________________________________________I I I 1 PHONE # I '---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII---------------------------------------------------------------------------------------------- TANK ID # TANK SIZE CENMICALS SIOEED CURAEMLY/PREVIOUSLY MTE KIST INSTA= I 139- 1 -1, oso pKN.A�,Aw JrA�c.�ded I T 139- 2., J..Irma I A 139- N 139- I K 1 39- 39-_ 9-39- I I 139- P I ___IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIiIIIIIIIIIIIItlltlllllllllllltllllllllltlllllllllllllltllllllll I �[ I I L I _APPROVE APPROVE WITH WNDITIE(S) _DISAPPROVE I I A I (SEB ATTACWdHN1'WITH WNDITIONS) I I N FUN EzvMwEns EAME DATE a---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII11111IIIIIIIIIIIIIIIIIIIIIIIIIIIIII{III L'IIIIIIIIIIIIIIIIIIIIII IIII III IIIIIIIIIIiill I APPLICANT WE/Sf PERFORM ALL WORK IN ACWRDANCE KITH SAN JOAQUIN COUNTY ORDINANCES, SCATB LAMS, AND RULES AND RHGtRATIONS OF I I SAN JOAQUIN WUNTY, ENVIROWRI@lPAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY TRAT IN THE PERFORMANCE OF ME WORK POR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EWPIAY ANY PERSON IN SUCH A WANNER AS TO I BECOME SISSECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CIXTIRACIOR'S HIRING OR SUBWNTRACLING SIGNATURE CERTIFIES THE FOLLONING: •I CERTIFY THAT IN TRE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBSECI TO WORKER'S WWffENSATION LAWS OF CALIFORNIA." Cy'/UO� I 1lI ve O. APPLICANT'S SIGNATURE! TITLE —""o& ka 1_– GA. 8/1O/Oy '--------------------------------------------------------------------------------------------------------- * c�cso c��vaas 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 V4ll`9P&6 �' Address I&& F,�Nk west Phone#1( Zpgf qn-q y/1 Skocv,(-- CN 4S2o1. 1