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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE. SID FLOOR STOCKTON, CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FRCM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: ,REr7 0/--/' TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +----------------------- ---------------------------------------------------------------- I EPA SITE # f 1 PROJECT CONTACT & TELEPHONE # (,d �� FRES�fO Lire - --- +------------ - --- - - - - - --- ---- ------------------------------------- CS��Bsriog ----------------------- FACILITY NAME PHONE_4 C I ADDRESS ------------------ ' 3o s W � 60A-1 cvg --- ---------- --- - --- - - - 1 I L 1 CROSS STREET W S H (I�+ G 7-Z) N -- ---- - "- = +- ------------------------------------------------ ----------------------------------------------------------------------------1 I T I OWNER/OPERATOR 1 Y I 6p WE5T Cad} -ST PRoocte-773.,, LLC. 1 PHONE #�C,.0(, ,4- 3335-- 1+------------------------------------------------------------------------------------+--------------------------------------- 0 ----- - ------ -- - ---I C i CONTRACTOR NAME T ✓1 T �� r ♦ i PHONE # ----------------------- ---------------------------- I N I CONTRACTOR ADDRESS y�-------------- -------------------- T --- - -1 ---------------�8 - L Ll Flu Ill G D/\ -- LIC # s�s/-- 1 CLASS CID !3 A% /SPS$ 1 R I INSURER %�=�-/ � _ _ _ _ _ r i WORK. OMP. X GG 0 -01 �A G 1 1 C 1 OTHER INFORMATION T+----------------- 1 I -----'--------------'---------:------------------------------------+------- -------------------------- 0 1 1 _______I R +----------------------------- PHONE # PHONE # +--111111111I11'1111IIIIIIIIIIII -'--"--- 1 III--------------------------------------------!---------------------------------------- TANK ID #I 1111 I I 1 V III 1111111 I II I 1 TANK TE CHEMICALS STORED 39- 1 7�5 � r 006 I CUgg LY/PREVIOUSLY1 DATE UST INSTALLED 1 I T 1 39-I C. �-i �i E N 1 39- I / 9.L�C/Ci , 1 1 K 139- i 1 39; I 139- 1 1 1 I , 1111111111111 VIII 111111 IIIIII111111111111111 III II 11 II II 11 1 I I I III 1111111111 Illi) 111 II Illi Illi +---11111 11 111111 IIII IIII II it II II (IIII IIII I1111111Ii 1111111111111111111 I1I1IIIIIIIIII II 11111111111Il 11 11 lllllllllllllllill 111 ' P I 1 � I' I r_ APPROVED _APPROVED WITH CONDITION (S) DISAPPROVEDsr� .^ ( FATTACHMENT WITH CONDITIONS) DATE ✓ -✓ i I N 1 PLAN REVIEWERS NAME u� Q {0 +" l I1111��ii1 �i III II11111 11ii1i11i1iii i 11liiliiiiiillliii.,i I;II I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 1 I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I 1 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 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." 1 1 1 1 I 1 I 1 1 � I L / 1 E I APPLICANT'S SIGNATURE: TITLE 'L � DATE I I 1 ---------------------------------------------------------- +--------------------------------------------------------- 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 6P 13k('() Address I/ eepi tf r- )0orrc 1C lair , Phone #,�7() 6qL-333 — Signature P141 4'nlq , e� �� z 3 I `T' EH230038 (revised 1/31/02) 1