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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3 R 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 +-----------------------------------------------+- { 1 EPA SITE # PROJECT CONTACT & TELEPHONE # I+-------------------------------------- ------- q�-----------�-----T �. _ { F 1 FACILITY NAME e}l t= 0,0 E , jwf V(PE of E 9 1 PHONE # d _ 1 I A --------------------------------------------- - , - j 9 -�� 98a I -- p- � -------------------------- 1 C I ADDRESS _I 6. ( � f- ��E i e_ A, 4i j �� ---i ' I +------------- _ I L I CROSS STREET I +---3/----------------------------- -- ------------------------------- 1 T 1 OWNER/OPERATOR PHONE #------------------------ I Y IItJ0..Q-8-9�a ---+------------ ---------------- ------------------------------------ 1 C 1 coNTRAcroR NAME {�) 1 C w / C� j�1 ri ('��f�lJS 1 PHONE #% / r^ --- N CONTRACTOR ADDRESS �� C7� �� CA LIC # �j�O�'7/ 1 CLASS I T +------ ------ --- ----------------------------------------------------------------------------------------------------------- R� INSURER ' I I 1 WORK.COMP.# 1 ------------------------------------------------- I C I OTHER INFORMATION I T+------------------------------------------------------------------------------------+----------------------------------------' 0 1 1 PHONE # R+------------------------------------------------------------------------------------+---------------- ------------------------ +---11 II I I I 1 1 1 1 I I I 1PHONE# IIIIIIIIIII111111111111111I11111-------------------------------------------------------------------------------------- I I TANK ID # i TANK SIZE i CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED 1 I 39- I I T 1 I 39- 1 1 o a A 1 3 9- I , bD n � 1 I_ T' Ree v I 1 N i 39- i 1 K i 39- 39- P 9 -39- P IL A I IN 39- 1 IIIIIII111111II11 1 111IIIIIII 1111111111111111111111111111111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII!IIII!11111111111!11111 _ APPROVEDAPPROV WITH CONDI ION(S) _VDISAPPROVED 1 I cY�•`7��5 I PLAN REVIEWERS NAME �/v C�.,I�E T H ONS) DATE AZk-\00\\ IIIIIIIIIIIIIIIIIII111 I-11PIIIIIIIIIII IIIIII III H111 11111)411I1I I741)111 I11I 111111IIIIIIIIIIIIIIIII11111111111111111IIII APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUI UI Y ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS 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 BECOME 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA.- APPLICANT'S ALIFORNIA." APPLICANT'S SIGNATURE: �` aot / i TITLE 0 N� N a d( DATE 4 ` c A --------- ------------------ -------------------------------------- ------------------- ------------ -------------- ------------.--------+ 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 kAh 14 -kW A Address AAJ r Phone # 2�vq Signature u 0_!Ij,, EH230038 (revised 1/31/02)