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0 • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3`m 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: _)C TANK RETROFIT ____PIPING REPAIR/RETROFIT ____UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT --------------------------------------------------------------------------------------------g f -118 ------- EPA SITE # PROJECT CbNTACf s TELEPHONE # I AA (C 14 a 6l WAC -T-09 �, 3 ' � � SQL' •------------------------------------------------------------------------------- '-----------'i F FACILITY NAME-----� 114IG___ `� ro " _____-------------------------------------------------------- C PHONE_# �"`IO S �,S•O O A______________ C� /y.�/, A ___________________________________ _ _ C 1 ADDRESS - ?- --- ''--P Q w� Yet E m C.%�-'---- --- To c Zroi. _C A----- I s, t O g------,� L 1 CROSS STREET --_-�- 2 I --- E--- E--------------------------------------------------------------------------------------1 •---------------------- I T L OWNER/OPERATOR 1 PHONE # Y Q U tie -o P- KA A-A.K. '-rs I -- s�o - (o r 8 so° ------I NAME PHONE #_ 3 J, 3 l l r Z- 1 C CONTRACTOR-------------------- ---�� L T-0--- __ E -- -- (� l----- --------- /ii c _-------I----------� ----------`---------------- N CONTRACTOR ADDRESS P� O. o X, g ` CA LIc # Z 3 CLASS A . B . µl) Z ldl:---� A 4,-� , {' A - 49 _r fo------ --- - --------------------------------- -------- T.---------------------- C r R 1 INSURER STfj'TE i:J r,�D WORK. COMP.#_�_f3 IJG Z� - O Z 7 -J-'I--'-----------� C 1 OTHER INFORMATION 1 0 1 1 PHONE # R_____________________________________________________________________________________+________________________________________I 1 PHONE # •---iiiiiiiiiiiiiiiiiii1111__________________________________________________________ TANK ID # TANK SIZE 1 CHEMICALS STORED CURRENTLY/ PREVIOUSLY DATE UST INSTALLED 39- O i io,po 0 1 (,'4S0L0^(G. V"IL T I 39- O L 1 (0 '000 A 39- N 39- 1 1 'i K I 39- 39- 39-_ 9-39-39- 1 •--1111111111111111i11111111111111111111111illlllllll 11111111111111111111111111 II 1111111illlllllililllliiliiilllilllll1111111 P LAPPR VED APP i OVED WITH CONDITION (S DISAPPROVED A 11 (SEE A WITH CONDITIONS) N PLAN REVIEWERS NAME I1111IIIIt1111111111111 11111 11 111111111111111 IIIIIIIIIIII11111111IIIIIIIIIIIIIIII:I1111111111 1 111111111111111111111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 1 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 COMPENSATION LAWS OF CALIFORNIA." TITLE 1 IZ vt CO DATE APPLICANT'S SIGNATURE: y -�-{-- 4004 _________________________________1!N (CU4Fs�___E_'__WA �T------__________________________-_______________------------ BILLING INFORMATION: THAT IN THE WORKER'S 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. 'Bo -C foal- 1716 Name_�u 4 _WA tTt+ Address—_�-L 5; X e� _ � A �sb �r __Phone #_}: i__- --- __