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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 - ------ ----------------------------------- I EPA SITE # I PROJECT CONTACT & TELEPHONE # A N R `_- 1 I +--------------- --------- - ---------------------------------------------- `------------------ -, .? v ------------- I F I FACILITY NAMEQC� ,ny/ I PHONE # 1 I I ADDRESS r /'1,�_-,j-I 't�-- LY L2SJ T}1N I I L I CROSS STREET__ M M F p ` A p F I +----------- - --------- ------------------------------------------------------------------------------------i T I OWNER/OPERATOR I PHONE # J Y I QP w��T CCAS)----- P/,�(�,jc_TS � �- la -�7(3- s �C� I I 1---+—-- ---- '+------------'--- -- --- ------- -------- ---------- --------- C I CONTRACTOR NAME V I PHONE # (, �� ' I o +------- S . 1 W F A E ------------------- ------ --_ -i ------------------------------------ ------------------------------- N I CONTRACTOR ADDRESS r� �L N U=-_- V StW(- I CA LIC # 1 1 CLASS IT +--------------------Q4�4�-�-- -'-`----- ---- �-----1- �-+c• - 1�--------------- --�---,-1--d --�---`---I R I INSURERI WORK.COMP_# -- T- ---�0-- ----------------------------J-------- ----------- C I OTHER INFORMATION I 1 -----------------------------------+----------------------------------------I I 0 { I PHONE # I R +------------------------------------------------------------------------------------+----------------------------------------i I PHONE_# I +—"I 1 II 11111 II III II II I —-----------------------—------'i-------------------------------------------------------------i I {II { IIIIIIIIIIIIIIIIIIIIIIIIIII 1 I I TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I I 139- I I I I T 139- I A I 39- I 1 1 I I I 1 N I 39- I K I 39- 39- 39- 9- 39-39 1111111 I 1 11111111111111111 111 111;IIII7IIII IIIIIIIIII111I1IIIIIII111111111111111111111II {{IIIIIII111 { I { IIIIIIIIIII IIIc IIIIIIIIIIIIIIIIII IIIIIIIII{ 111 111111111111IIIII ISI 111 I 111111111111111111111111 1111 111 PI I L I APPRO ID APPROVED WITH CONDITION(SJ, DISAPPROVED I -�q�E�)ATT CHMENT WITH CONDITIONS) ^+ N i PLAN REVIEWERS NAME \V DATE 21 +---II { IIIIIIII III IIIIIIIII II I I I I (IIIIIIIII II III1111IIIIIIIII III III III IIIIIIIIIIIIII � II 1111111 {{I II I II{II II II II 111111 I I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 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 I 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 I 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA I I I I I APPLICANT'S SIGNATURE: TITLE 14 G�w-r 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. SAaSL)� C,A A< < �ft bL. , Name , u Address S AC k A k 11 l-i C A Phone # ? �Q�- �� l Signature Y EH230038 n ' (revised 1/31/02) 1 "