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09/.12/2003 15:15 2094683433 FIFTH FLOOR PAGE 03 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3RO FLOOR STOCKTON. CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN 70AQUIN COUNTY ORDINANCES, STAT£ LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I I ?HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I4 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF TEE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL CLOY PERSONS SUBJECT TO 1 I WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE! i TITLE y[ ( �� =s ��Jtk / DATE i --- --------------------------------------------------•-•_ ------------------------------w BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit paymeni 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 - 5918 Sf ER1d9� MAI( )A. Name SA4Ew" Address pitA"m4a>J y cry . 54588 Phone Signature EH230038 (revised 1/31/02) 04 THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE_ DO NOT WRITE IN ANY SHADED AREAS, INOICATE PERMIT TYPE BELOW: TANK RETROFIT ✓PIP)NG REPAIPURETROFIT UNDER DISPENSER +--------------------------------------------------------------------------•----•------------------------------------------------ CONTAINMENT REPAIR/RETROFIT 1 I EPA SITE A 1 PROJECT CONTACT 6 TELEPHONE # I---------------------------------------------------- ------_-------------------- F I FACILITY NAME At Ewt+. F- eeHtEe Z&00 ' PHONE # 1 A--------------------S=...------`1----Fo I C I ADDRESS ! Y_ !�I I 1 L +---------4...._ _ -- -------------------- I CROSS STREET I I +------- --------------------------- ------------------------------------------------------------------------------------------- ' 1 T Y I OWNER/OPERATOR Bv�ta��------------------------- PHONE lk I I I ----------------------- C CONTRACTOR NAME ' FlIlrvcc. Co�cs-F�---� INc_ 1 PHONE # '••• SU -Ne I o------------------------------------------------------------------ --------------- N CONTRACTOR ADDRESS LIC #ASS 1 (033 Ss�or- 4 No 1 �` -- -g1(. ---------------------i 177 9 ZrZl AR :aA�� IT R ----------------------- ................ ............................................... I INSME------R �, C '� VSD --------- -4�-C,---' WORK -COMP (o9ZZSfIZD I C I OTHER INFORMATION - IT+•------------------------------------------------------------------------------------i................_..........._......-----i 1 0 1 PHONE # 7y5/+/OV'� l IR+----�-------------------------------------------------------------.-----_----.----- ---------- - ----------------------I I PHONE #-----------; +-- 1111111111111111111IIlllllllllll------------------------------------ -----------------------------------------------1 TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED 1 I 139- 1 T 1 39- l A 9-N 139- V 39- I I i r K 39- I 1 39- 39- 111177-11111 111, -P-VIII I 1111111111111111 ill ill I ill 1 Hill iii IIIill IlillIII Ill l IIIIII[Ilr1 I 1 L I APPROVED _ APPROVED WITH CONDITIONS) _ DISAPPROVED 1 I A I (SEE ATTACHMENT WITH CONDITIONS) I N +--_I I PLAN REVIEWERS NAME III 11111:11111111111 III I I IIIIIIIIIIIIIIIIIIIIII 1 11111111 ITTTIII Ill Ill 1111111111 DATE 1111111 1 IIIIIIIIIIIIIIII1111IIIlII APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN 70AQUIN COUNTY ORDINANCES, STAT£ LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I I ?HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I4 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF TEE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL CLOY PERSONS SUBJECT TO 1 I WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE! i TITLE y[ ( �� =s ��Jtk / DATE i --- --------------------------------------------------•-•_ ------------------------------w BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit paymeni 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 - 5918 Sf ER1d9� MAI( )A. Name SA4Ew" Address pitA"m4a>J y cry . 54588 Phone Signature EH230038 (revised 1/31/02) 04