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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 REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> +--------------------- --------------- ---- --------- ------------------- ---r-- ----- + <br /> EPA SITE # 1 PROJECT CONTACT & TELEPHONE # M(CN X F-L. �A L'1 n( 9!( <br /> +----------------------- ----- <br /> ------ ---- ---- --- <br /> F ; FACILITY NAME (�o i v- S T--°f'P %F / 3 Z ; PHONE # <br /> A +___________ ---_v__________________________________________________________________ __________________________________ <br /> C ; ADDRESS 3 S 157-1�- W A VA vA F_tL <br /> L I CROSS STREET <br /> ------- ---- ---- ------ ----- <br /> T OWNER/OPERATOR PHONE # <br /> YuI(& S1ron W A-n/GErS s3 <br /> ,� so - s o <br /> C ; CONTRACTOR NAME (//A L'ro�t JK c- PHONE # ?t6 3:,-$ -its-*z- <br /> 0 +--------------------------------------------------------------- 3 & _PAZ— <br /> T N ; CONTRACTOR ADDRESS_$O n_-/ooZ s- W- S '�__9-S 6 9 l __ -CA LIC # _(�2 P CLASS A 8 g A Z <br /> -- ---------------------------- <br /> INSURER _T/�-rE _ _ __ ______ _______+-WORK_COMP_#______ _ __ L <br /> A ------------5 FL/ --------------------- 3 `�-z ° <br /> C OTHER INFORMATION <br /> -------- -----+----—----- ----- ——--' <br /> p , PHONE # <br /> PHONE # <br /> ----------------------------------------------------------- ----- ------------- <br /> 11IIIIIIIITANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 1 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPR UED WITH CONDITION(S DISAPPROVED <br /> A ; SEE ATTA MENT WITH CONDITION T <br /> N PLAN REVIEWERS NAME c DATE tJ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN J QUIN 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 <br /> 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 <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 <br /> WORKER'S COMPENSATION LAWS OF CALIFO IA." <br /> APPLICANT'S SIGNATURE: TITLE Q��IZ A'C/y-O h DATE <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 <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> p. 0, B 0 / ozs" <br /> Name UJA Address W . S 4-LA--e , Co- 7(s-6It r Phone # X1/6 <br /> Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />