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FROM :TLM PETRO LABOR FORCE FAX NO. :5629238138 ul. 28 2004 01:01PM P4i7 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3pD FLOOR STOCKTON,CA 96202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 9D DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: ,TANK RETROFIT _PIPING REPAIRIRETROFIT _UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT +-------------------------------------------------------------------------------------------------- ------ -------i EPA SITE # PROJECT CONTACT d TELEPHONE # AIS Tom 31p ZSR+I6- 1�--111--------------`----41 -__-- ---------------I F 1 FACILITY NAME �Ay,rw 6313-- --- :_PHONE # �f1- A-Z S 6'f P4 /1 W VVV✓ V�--r ----t---------C---, Ma'h 5 r --- 1. 1 C 1 ADDRESS 1 loo 5 � ------------------------------------------------------------ i CROSS STREET ac ' I +----------------------�h.Vl.l�a2 �a --------------------------'---------------------------------- '-------------'1 T I OWNER/OPERATOR STP w� Coq s+ Prwio4t's4 LLC PHONE #� Y irk .---+------------------------------------------------------------------------------------+----------------------------------------i C CONTRACTOR NAME TLM ''�+yo LAkIe N c,e 1 �,---------------------------------------------------- N '-- ___----PHONE # S6z.g23.yM2_ 0 +------------------ '-----'-'------------;------_"____r - �-_+'�__ w,__,,.��- -- - - - - - - -- ----- 1 N CONTRACTOR ADDRESS ++L �p, c�. CA LIC # I J M J I CLASS R i INSURERIT'Iii -- ----- f fr}1/ 7V---04 y ,>----- - ----- -- --R -CM #---------------- ---- ---IA ----------------------------------- + C OTHER INFORMATION ' , T +------------------------------------------------------------------------------------F----------------------------------------1 1 0 I 1 PHONE # R +__________________________________-._-_____________________---___--__-_____-_____---_+_ ____---______---____--__-_---_--.--___ PHONE # ---------------------------------------------------------------------------------------------- ' TANK I1) # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE U T INSTALLED ' 68b Itims, all -- 1113 141- T 39-_DWD ILIM LPL.- 2i1 CwCAC --i ---- --- __- 1 A 1 39-� � --....._-- N , 39- — K 39- 39- 39- 9-39-39- _ I- +---, ......, ,,,ri, 1P1 I. ! APPROVED %�Y APPROVED WTTH CONDITIONISS DISAPPROVED A 1 SEE ATTA ITH CONDITIONS) A/ I N 1 PLAN REVIEWERS NAMEpvpi✓ �� - _,..,,._ DATE _�� „,„1111 ii lii 11111 AFFLICANT' MU-5T FF.RFOHM AW.VX)KK 1N ACCORDANCF WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND 1U=LATION1'3 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 THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO HECK SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 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." ACFLIOANT'R OIONATURE: TITLE __. 1 -DATR �/e� +_________________________________________________________________________________________________________________________________+ BILLING INFORMATION: Indicate the responsible party to be billed for additional EHL) staff Ume expended beyond permit paymem 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 TLA (04 a&L e) Address Phone# 1