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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3"D 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 +-------------------------------------------------------------------------------- ---------------------------------- __ ______________ EPA SITE # ------------------------------------_ ' PROJECT CONTACT & TELEPHONE # I ------------- __ Wim. p F ; FACILITY NAME ------------------ - ----- - A+- - ------------------------------------------------------ C: -- ) PHONE # I C; ADDRESS W �'t" . I +---------------18�_ �!__ Z�ro._c _ 6,4 L ; CROSS STREET--------------------------------------------COVI . G LL„- �1 �w I-------------------------------------------------------------------- T OWNER/OPERATOR ---- Y PHONE ------------ ` # QA '_$b ;� C I CONTRACTOR NAME �� . . �• � . /y � � � .. PHONE ' '#' •_:-____ �. . I O +-----r------------�----- -- `-�=`h'V-`t' Lei �'"l' �S i -V+------------------------------------------------- T ; N CONTRACTOR ADDRESS/fir A I -------------------- -6Lt.---�-y-�,� fi_ CA LIC # 1 CLASS I R ; I------ ,eA�.,..,✓1 �/� C- Cl''��n I44-.Y(�1�L------------ +_WORK_COMP_#-V�1� a'�1JC��-- - C ; OTHER INFORMATION ------ r T +------------------------------- --------------------- I -------------------------------- I R + ---I rrrrrrrr�rirrrrrrrrr�rr��r�rrrrr�rr ;;;); I,,,r ' -- I PHONE # ----------------------------------------- ----------------------- PHONE # TANK r ID # TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED 39- T 39- A 39 - IN 39- K 39IV - 39- 39- / I L APPRO APPROVED WITH CONDITIONS) DISAPPROVED A I�Ix=EATTACIHIMENT WITH CONDITIONS) N ; PLAN REVIEWERS NAME DATE / u APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY .. .. ..THAT IN THE. PERFORMANCE OF THE .WORK FOR WHICH THISPERMIT IS ISSUED,;- I. SHALL NOT EMPLOY ANY 'PERSON '.SUCH BECOME .A .MANNER A$ .TO BECOME SUBJECT TO WORKER'S. COMPEN$ATION LAWS'.6P.CALIFORNIA'.`" ..CONTRACTOR'S AIRSNG OR SUBCONTRACTING(SIGNATURE ANNECERTAS THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,. I SHALL EMPLOY PERSONSSUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: 141 -h--eTITLE QU64&-VDATE �L r --------------------------------------------------------------------------------------------------------- -------------------------- 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. NamelaA+R'r0J U. a-)LWk*jiAddress�b &QZM&X, 5T,CA %101— Phone# -0 Signature Zug- U, it! EH230038 (revised 1/31/02)