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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3R0 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 +---------------------------------------------------------------------------------------------------------------------------------+ 1 EPA SITE # P A C/a O d q I PROJECT CONTACT & TELEPHONE # C 91rr ll, DOWDY o 0 *G/-G 33 1 +------------------------------------- --------- -------------------------------------------------------,---------- I F I FACILITY NAME V TOPS 4 A N D _D E V E l- O P M G N T_ { PHONE #�i�0 9' 8 —3— 3 313 IA +-------------- -- ----------- I C I ADDRESS 13-% 4 E, D S C- rz ; -7t M a w ]-Q C a� J � ' I +-------------- ---------- ------------- ----------------------------- ---------I PaoxE---------------------------------- 1 L I CROSS STREET �v w ----`--�- ' I T OWNER/OPERATOR f Y I d -e /tea ��er r► s es 1 � 9� f---+----------------------------------------------------------- ------------------------+------ ------------------------------- C ' CONTRACTOR NAME 20 q) I -------------------------'_PHONE -- Y I N I CONTRACTOR ADDRESS � -3 S-___- 0.--- -�-- CA LIC #6,6 V6 = CLAS -- - -- r---------- --------- _ S ----- R 1 INSURER ----j=---�----------- 1 T' �� U N Qr_ I WORK.COMP.# / 1W / I ' A ----- --------------------------------=-T-------------------------- V` - -- co !1 I C I OTHER INFORMATION I IT +-----------------------------------------------=------------------------------------+---------- q { 0 1 1 PHONE # O )J f ' R i------------------------------------------------------------------------------------+-------- ��--- 3,.�z-7--- 1-PHONE # +---Ifllll{I {1111111{if{{Illlllllllf------------------------------------------------------ ---------------------------------------{ I I TANK ID # 1 TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED 1 I I 39- b o PS--e- w. • I T 139- OOf ;3I I n 0 4 i 42 2y i iT%L A l 39- 4 fy cy 00 1 i o n I N 1 39- I� I I K139- f 1 1 I 1 I 139- 39- `---'VIII{111{I{{IIIIIIIII111111111i1111i11{{111{1111 Ilii{11{1{I{11111111{li{il{IIIIIIIiiiIIIIIiiIIIIIIIIIIIIlill1111 {111111{Illi P 1 L I PROVED ` APPROVED WITH CONDITION(S) _ DISAPPROVED I I A 1 (SEE ATTACHMENT WITH CONDITIONS) 1 N I PLAN REVIEWERS N DATE Q 3 I +---IiiIIIIfIIIlifI111 III X111 11 '1' 1' � '111111 1111111111111111111111117.-11.,11;11111111111 i1 111;111111111iiiIIiiiiiIIiIii I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 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 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA." i { I i APPLICANT'S SIGNATURE: TITLE t �- /"�� DATE �z I +---------------------— -- ----------------//- ---------------— + BILLING INFORMATI N- 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 �(r�te -Q7C'ogc� Address ��3 S- LVr Z ulca'w` Vv--, Phone Signature �'z ZU66��= i EH230038 (revised 1/31/02) 1