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j' P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3RD 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 +----------------------------------------------------------- ---------------- I I EPA SITE # - PROJECT CONTACT & TELEPHONE # I +------------------ -------------------------- 78 I F I FACILITY NAME _W I SE f� _ N�r / /� PHONE # �/�Q 2-3p-77_C_8__I Iq 5 . ih I C I ADDRESS L l CROSS STREET `.'S-rW 09M I T I OWNER/OPERATOR I PHONE k I Y wjf-Tfw��rP6� 11101- ----�- --- �Q-5?7-_(oE�D4 ----i 1 C ICONTRACTOR---------- NAME LG___SEIZVIGG S---------------------4111%------I---------559:78 730---I 1 N 1 CONTRACTOR ADDRESS LZ� N. YaRK4_I 6W T F,r,�. Mo 1 CALIC # Z/ CITSS 1 T ------------------------------------IV I'f r1FJK�� 1 R 1 INSURER I WORK.COMP.# 1 Fres _ -----Co ---vP�.s$�--Q4---00-------------------------------------------- Cr -r , 1 OTHER INFORMATION __ IT +------------------------------------- _______________________+_____� �----��-�-p�--------I 10 1 1 PHONE # 1 1 R +________________________________________ ____________________+________-__-_______________-____________1 1 t I PHONE # 1 +___IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII_________________________________________________________________________________ -__1 1 I TANK ID # TANK SIZE I CHEMICALS STORED Y/PREVIOUSLY 1 DATE UST INSTALLED 1 j39-.0W2__'&1&4330 I DIESEL I 917 1 T 139- Ia- /DL 1 "luL I_ 1 7 1 1 A 1 39- 1 26 L-6 I I IN139- t t 1 K 1 39-_ I I I I 39- 39- P 9-39-P 1 L I _APPROVED XAPPROVED WITH CONDITION(S)* _DISAPPROVED I A I ATTACHMENT WITH CONDITIONS) N 1 PLAN REVIEWERS NAME� \, DATE +---111111111111111111111111111111111111111111111 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Illillllllllllllllllllllil I I 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 1 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 I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I I I I I APPLICANT'S SIGNATURE: .j/y TITLE OPFJOAC 1011 S DATE i 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. NameAddress____ ___Phone# 1