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SAN JOAQUIN COUNTY ENVIRONMENTAL L 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 DISPENS �CONT�AINENT REPAIR/RETROFIT +-------------------------------------------------------------------------------- -EPA SITE # - PROJECT CONTACT & TELEPHONE #-------------'--- - - --- --- ---------------------- -----!T F I FACILITY NAME PHONE # 1 A +----------'---- - --- --------- ------------------------------------------ '-------------- F ! --{ j C I ADDRESS ------ - - - ------ - - i j L I CROSS STREET I I r-------------- --------- ---------------------------------- ------------- ---------------- I T { OWNER/OPERATO PHONE # i Y I { +------------- -- --- ---- - --- - --------- { C { CONTRACTOR NAME � j PHONE # � ----94 --- - - ---� I0 --------------------- - ---------------- -- j N { CONTRACT DRESS -- jT +------- M-- -- =-----l-CA-LIC__Alf _ �- ----,_CLASS- --�-i�-� -� { R ( INSURE ------ -----------WORK.COMP.# I A I- ------- - -------------------------- - ---- ;� C { OTHER ITION - ------ - - - I-------------------------------------------------------------------------------+----------------- - ---------------------{ I 0 I I PHONE # R ------------------------------------------' i____________________________^_------------+--------------------- -----{ -� PHONE # { +---I{1{11{1111111111111{III{1111111------------------------------- ------------------ ----------------------------------------I I I TANK ID # j TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED ! { 39- 1 T { 39- 1 A { 39- 1 N I 39- 1 K I 39- 9- 39- 39- 39- 3P P {LI IAI { N I PLAN REVIEWERS NAME *---I{I{{{{1111{{{1111111 { APPROVED WITH CONDITION(S) DISAPPROVED A T WITH CONDITIONS) DATE I I I H IrA IT! H IIIIIIIH111 11111111 1111111111{1111{{.1 1111'Will III{{III{{{{{ j APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I I 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 I THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I WORKER'S COMPENSATION LAWS CALIFORNIA." { j { � APPLICANT'S SIGNATURE: TIT &T41VDATE � I i i 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. Nam62h&�Address_ h,1 l CPhonel—&II-635,7z Signature, / 1 (revised 1/31/02fat �{ 1 y 1 . r i r.