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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3�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 t_________________________________________________________________________________________________________________ _____t I I EPA SITS If I PROJECT mxxncT R nI.RPHONS # +________________________________________p___________ _______-______________-- _____ _______________________--_______________I F I FACILITY MM U I* (] ��R. P�M.I ,Sty ' /�{ PHONH # C-100 75e- ?o-? I I C I ADDRESS I I +------------ 30 ' rL--------------------------- I I _____ L WC(M4 J _CII t-_______ _____________ -___ T ONNIWOPERATOR I PWOaS # I . III IV4 (IPC �Z P1k4 � Seef)i �s ---+---------------- __ - ------- j---- c (z - i i � -------------------------------- c I LUNrnncrae FAFffi V`'__�•• G�vc -c.....w.. �ID KS�_ xxw• I PHONE # (S3o I I D t--------------------��-----5`-------Q------`- ------------- -- -- 87---L83 G - ----------------------------------------- - N CQiZBACFOR ADDRESS �.- �px---1t4 1 A.6K<'Y3 LA 1510y CA LK # *r0 Zi38 I CLASS �¢ SKn'MI I T _________________________ _ ^ _ _________-___________________________________-___________________ ___________-_____ . I R INSURER S^F4'C eti-'k I WORK.cmMF.# I IA I____________________________________________________________________________________t____________________________-___________1 I C I OTHER INFDRMATIQI I 1 Tt___ _________________ ___________-_____________-____________t____-________________-__________________ OI 1 I PHONE # I I I - I ----- # I ___IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII_______________________________________________________ __________________________________I TAFIX ID # I TANK SIZE I CHEMICALS SNONSO CURRENTT.Y/FREVIWSLY I DATE UST INSTALLED I 139-- I I 1-1 IT139- I 1-1 IA13s- I I I IN139- I I IK139- I 1 1 39- I 1 1 39- I I I ---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII,IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII11111 III IPI ,L/ I I L I APPROVED APPROVED NIMMMIMW(S� _DISAPPROVED I A I (SEE A it'Y TZONS) N I PLAN NEVISWBRS [ATS 9 ___Iitllllllllllllllllllllllllllllllllllllllltlillllll IIII II Illllllllllllillllllli 1111 IIItill IIIIIIIIII IIIII I APPLICANT MUST PERFORM ALL NOFUC IN ACNRDANCE WITH SAN JOAQUIN COUNTY BS, STATE LAN3, ASID RULES AND REGULATIQi3 OF I SAN JOAQUIN CO[R]TY, SNVIFDNMENLAL 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 I SEC SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." OONTRACNR'S HIRING OR SUBCONNHACTING SIGNATURE CERTIFIES THE I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF TFL: WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORKER'S COFPENSATION LAWS OF CALIFORNIA." I I i _ I 1 APPLICANf'S SIGlA10RE: _ TIME l.^�d"O414 /-•"�^�S DATE �-' /� 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—___--_—-----------Address_---_–__–__ ----------------Phone#------------- 1