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.r <br /> 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 /> ---------------------- -------------- <br /> 1 EPA SITE # PROJECT CONTACT & TELEPHONE # <br /> 1 --------------------------- -------------------------------------------------11-//-11= <br /> F 1 FACILITY NAME #PHONE 7 <br /> r )gyp <br /> I A +------------------=- uT------ --- <br /> ---------------------�--q--------- --------/�-°r/-C-"1---9a--�$� -- <br /> I C 1 ADDRESS ��_�` p���► � Y '�Q' ��5�_�-F�� l s�� I <br /> L 1 CROSS STREET <br /> ' I +-----------------------------------------------------------------------------------------------------------------------------' <br /> T 1 OWNER/OPERATOR PHONE # <br /> ---+------ �_� T ?_- . <br /> Af -_----�� <br /> Y 1 � _ 1 <br /> , <br /> C 1 CONTRACTOR NAME J i)0_1 Q --p�� _ --- PHONE # [���-- ([ <br /> 0 +------------------ --- ------------------------------ 1!� (- <br /> { N CONTRACTOR ADDRESS-`��-\n_ ` ---/� - -------/----�-'-/-� CA LIC # 55-----_cl.Ass gCb�/v�,lo yF------ <br /> Lai �..�I-cL�0 <br /> I R 1 INSURER �0._ Ste---f� -- _ - --- `- - --------lRK�------+-WORK COMP-#--2$S� O�l <br /> C 1 OTHER INFORMATION 1 , <br /> T +-----------------------------------------------------------------------------------------------------------------------------1 <br /> 0 1 1 PHONE # <br /> ' R +-----------------------------------------------------------------------------------{----------------------------------------' <br /> 1 PHONE # <br /> +---111,111111111111,,,,,,1,,,,111 ,----------------------------------------------------------------------------------------------, <br /> 1 1 TANK ID # TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED <br /> 1 39- U <br /> T 39- <br /> A 39- <br /> 1 N 1 39- z00� <br /> 1 K 1 39- <br /> 1 39- HEALTH <br /> , 39- <br /> I,,,,,,i,ii..i, ii, <br /> ES <br /> 1 P 1 <br /> 1 L 1 1 PPR ED 1, V APPROVED WI H CONDITION(1)I DISAPPROVED , <br /> 1 A 1 (SE ENT TH CONDITIO 2 , <br /> N 1 PLAN REVIEWERS NAME DATE ( d ©� 1 <br /> 1 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 1 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 , <br /> , FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." 1 <br /> APPLICANT'S SIGNATURE: TITLE? DATE (0 1 <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 <br /> �responsibility for the billing by signature and date below. <br /> Name C �c`� l �� T'r lib-Address �M A I V-\ (atm- ,kc_ CIA Phone #9/6-83� 5 717 <br /> 9S837 <br /> 1 <br />