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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3R°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 —9_ 6W kk}- <br /> i U- , <br /> +1--- -#--------------------------------------------------------------------------------r--------------------------- <br /> ---- <br /> -+ <br /> EPA SITEPROJECTCONTACT & TELEPHONE #-M � ---------- <br /> F <br /> Vk"-A $_A343$ <br /> +---------------------------------------------- - - _ - n- y --- <br /> F ) FACILITY AME -PHONE V7 � -- �/� <br /> A +--------------- - ---------------------------------------------------- - --------------------------------- <br /> C <br /> ----- - - ----S --- <br /> - - <br /> ' ---- <br /> C ) ADDRESS l� <br /> L ; CROSS <br /> , <br /> STREET---A--w4--- O <br /> - <br /> T ' <br /> OWNER/OPERATOR ; PHONE # <br /> Y ' Scot} -------- <br /> Ste-_4a.1-p 7?O--_-_ <br /> ---t---------------.--------�-y t-----.---^ -----------------------+------ ---�-J�p ¢ <br /> .: .). C CONTRACTOR NAME �1.�� V•�6%t � S, .. ) PHONE #'"*!j'0 �_ <br /> o +-------------------------------------------- � ----------------------- ---- - ---�4 <br /> ----- <br /> I N ) CONTRACTOR ADDRESS �� --Q'1 �� - 1/ ,-/1N (-v -;_CA-LIC_#_�Q�,��------CLASS <br /> r Y [ �'�'�-C LLMC 1 ..Ii7�t GG -----------+ -�---------i <br /> ) R I INSURER__4�'�L�_L- Q.hi��y/ 4�uLr �VLStti II�C�---------------� WORK. OMP.# 69a 13e-------------- <br /> As - - 1 - - -------- +------------------------ - <br /> 1 C ; OTHER INFORMATION <br /> I 0 I I PHONE # <br /> , <br /> , PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br /> 39- <br /> T 1 39- <br /> 1 A 39- <br /> N 39- <br /> K ; 39- <br /> 39- <br /> 39- <br /> +--- <br /> L ; / APPROVED , APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ; (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE q111111 <br /> 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 <br /> THAT IN THE.PERFORMANCE OF THE.WORK FOR WHICH THIS.PERMIT-IS.I•SSUED;•I.SHALL NOT EMPLOY ANY;PERSQN IN,.SUCH.A.MANNER AS .TO.'. ..;. <br /> BECOME SUBJECT TO V(ORKEh•'S. COM$E)`1$AxION LAWSr.O$.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 igSUED,-I*SHALL EMPLOY PERSONS'SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: p"�"l C4i-�'l> / L TITLEuse DATE <br /> �iIla4C <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 /> Name RRiZj16,( V LJ-LATQ it JAddress 06. 60? (Wl &e, SJ, 0A QS lt--�.Phone # q0t—a�3 D4, <br /> SignatureV� <br /> EH230038 <br /> (revised 1/31/02) <br /> 1 <br />