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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW. <br /> TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +---------------------------------------------------------------------------------------------n---�--�--------------------------------+ <br /> EPA SITE # ; PROJECT CONTACT & TELEPHONE # �j�q.tp C.q�,¢C/!t7 f�S 7U9 l954V <br /> +---------------------------------------------------------------------------------- -------------------- DDDR--------- <br /> --- <br /> ; F I FACILITY NAME 1� L /���Z�`' ;-PHONE # AO'?? 7�.�. UX77 ' <br /> A +---DRESS--------If//5 S, EL -Zd4{.� ---'2e'Vaq -------DDDR-- - - ------------------------- <br /> ------ <br /> C ; ADDRESS Cf/rit� C.%I 3/ ' <br /> ' I +---------------------------------------------------------r'�----------------------/------------------------DDDR- ; <br /> L ; CROSS STREET ' <br /> I +------------------ ' 5------------------------------------------------------------------------------------------; <br /> T ; OWNER/OPERATOR L //� ; PHONE # d <br /> Y ; Q//17-tG -FJN�E'-Z+Q 5t- T <br /> /� <br /> ---+------------------------- - ---------- ------------------------- --- +---------------------------"----------------; <br /> C ; CONTRACTOR NAME /!�.(�! PHONE # l�aJl�, 7477 � T'r <br /> cx.91� s�vr.¢d.Jr�c 9c. -4,1.v_4 g� T--------------------------------------,/--------------i <br /> N ; CONTRACTOR ADDRESS Pd. �� j%;2 y„1 ' P; CA LIC # ,SfC376Q ; CLASS <br /> T +------------�----"-�---�---------------------t-----�=_"'7 ----------------------------------------f---DDDR--DDDR---; <br /> R 1 INSURER <br /> C.6NQLj�S97`701� 51.L.Q.�T�C- ---------------+_WORK.COMP.# !6 Ps3�.2- aaa54 ; <br /> A '--------------------------- <br /> C ; OTHER INFORMATION ' <br /> T +------------------------------------------------------------------------------------+----------------------------------------; <br /> p PHONE # <br /> ' R -----------------------------------------------------+----------------------DDDR----DDDR------; <br /> PHONE # <br /> ----DDDR-DDDR---------------------- <br /> TANK ID # 111111" ; TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED ' <br /> 39- <br /> T 39- <br /> A ; 39- <br /> N ; 39- <br /> K 39- <br /> 39- <br /> 39- <br /> L ; APPRO ED APPROVED WITH CONDITION S) DISAPPROVED ; <br /> A SEE ATTACHMENT WITH CONDITIONS) r I <br /> N ; PLAN REVIEWERS NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> 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 <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE `-! � "��" DATE <br /> +-------------------------------------------------------------------------------------------------------------------------------+ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br /> coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> _ g//S S. �4 *4*�U T <br /> Name Address �sa�-rccl44 45.23/ Phone #. � <br /> Signature <br /> EH2300 <br /> (revised 1/31/02 <br /> 1 <br />