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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,10 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 /> +---------------------------------------------------------------------------------------------------------------------------------+ <br /> EPA SITE # I PROJECT CONTACT & TELEPHONE If <br /> +------------------- <br /> { F I FACILITY NAME /�,y_ I PHONE # <br /> A ----------------------------A MI <br /> C 1 ADDRESS ,1 00 JJ J`.H M A l t, "• A#,-TF- c A <br /> 1 L � CROSS STREET -----�---------------------------------------'---------'----------------------I <br /> 1 = +--------------- --- '-^-'S j4-S -�=N- p -- -- <br /> --------------------------I <br /> T OWNER/OPERATOR I PHONE # <br /> Y 1 %31? -- A- <br /> _- — ---- -- �v- <br /> -.T- ---'--(-�-�_ <br /> ---------------------;__1- 4 ---- - <br /> I c 1 coNTRACIOR HANE C� L t- (7- 1 PHONE # <br /> N I CONTRACTOR ADDRESS)("J ICA LIC #t i ) <br /> I I - / cuss ,Q.��(�t D 14 I f <br /> R I INSURER 'k, I WORK.COMP.# <br /> IA I______________ __________________________________________________,_______________________________ <br /> C OTHER INFORMATION I I <br /> 0 i 1 PHONE # I <br /> R -_____________________________________________________ <br /> _________________________ <br /> I I PHONE # <br /> 111111111111111111111i1111111111--------------------------------------------------------------------------------------------I <br /> ' I TANK # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE ST INSTALLED I <br /> i <br /> 39- 0 8 J 1 2"'VoI I '. PnGM jµV� I 1117 <br /> T 1 39- i Z.,9—,i;20—, <br /> i ✓JI <br /> A l 39 ��50� i � -,;2O I g 9 — M I A SR I I <br /> N 1 39' <br /> 1 K 1 39- 1 <br /> 39- I <br /> 39- { I <br /> +___iiilllillillliiliilllliiillilllillll{Illlllllllillllllllllllllllllllllllilillillllillllllililillllilllilillllliilillliillllllll <br /> P <br /> L 1 APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A I /�/7 SET: ATT404M"M" WITH CONDITIONS) (� �7 <br /> j N I PLAN REVIEWERS NAME U 1 <br /> +"-Illllililllillllllllill�ii Illililiillilllllllilllllillllllllllliiliiiiiillllllliliiiillllllllllilllililililllililllilllilil <br /> I I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND R93UTATICNS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY I THAT IN THE <br /> 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 I <br /> 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 <br /> COMPENSATION LAWS OF CALIFORNIA.- <br /> I <br /> APPLICANT'S SIGNATURE: f <br /> TITLE �✓/iy r� DATE <br /> I <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address Phone# <br /> 1 <br />