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�2C Ce 0 c --03 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WESER AVE,eo FLOOR STOCKTON,CA 95202 1 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 SELOV. _TANK RETROFIT X PIPING REPAIRIRETROFIT _UNDER DISPENS£RCONTAINMENT REPAIRIRETROFTT •----------------•----- ------------------......-•---•.......-..-.._.. ------------------------------------------------------------- EPA SITE 11 I PROJECT CONTACT t TELEPHONE N p• /C-1-aefJ ( 14) 5-101-4-q00 • ------------------•--------•----- ---" -•-------------- - ---- --------- --------------•I F I MILITY NAME AR CO 4 600 0 1 PHONE M C 1 ACOMS - 0-`J-- --4�4- l-��urSE AvE -----------------------------------------------/-TOP - ! I 1 L ! CROSS STREET ! li .-.. -- 1 5--------•-`------------------•--------------------•------••----------------.--.-..---------------•-! ! T I OWHEWOPERATOR 1 PHONE N ! { Y I St' K105T eOA-S± PP-0-Pa 7S I 1---•----------------•---•----------------------------------•------- -------------------------------------------------------------- C I CONTRACTOR NAND 7' ---------------------------------------------- N 17' 6!✓11e0A-//�/£jM i- ,`y6 i L 7 b ! P"� '(7/40 5?,-7-1o400 y � 1 NO .----------R ----' ------ CA LIG S i. ....-- -• y .. L ADORSSS 18b3 A1.NEV1t r.E S� .G.. _.'..----- .7 098 A �s$ 8�! to IT --------------------------------------- .._...--•------- I, 1"SuPmTRgJE�EfLS t+�DE-tI T�ITy CCJ. OF COId�tE�T1CU? 1 W*RX-COMM-o y n �yaQ 1 i C DIMER INFORMATION i I ---------------- --------------------------------------------------------------+---•------------- -----1 ! 0 ! 1 PHONE N ! 1 R --------------------------------------------------*--------------------*.............. ........_......................._..... 1 I I PHONE N 1 111111111111{{11111111 111!!Nill-----------------------••-•--------••--•---------------------------=--------------------------I 1 TANK EDN i TANK SIZE C1041CA1- STORED CVRRE"TLY/PRSVIOUSLY I DATE UST INSTIQ ED ! ! 1 ! T i 39' - ! A ! 39 1 N ; 39- I I I K 139- 39- 39- 4 9-39-39-• 111{f!!Illllfilllll111111111111l111l111111111111!!11!!{1111III{11111111111111!!11{111lI111lI{I111llllif111lflllllil1111i1111111 L `APPROVES APPROVED WITH CJNDITION(S) DISAPPROVED ! I (SEE ATIAC:*G 1'WITH CONDITIONS) A 1 I N I PLAN REVIEWERS NDATE NAM I 11lIlllllllllill11111l11111111111IILIIIItIk11111111!{IIl11111111111111!!HIM 11111111111{11111111111111lklffill111111i1lI1fl!! APPLICANT MUST PERFOia4 ALL WORX IN ACCORDANCE WITH SAN JOAOUIN C -1N'N ORDINANCES, STATE LAWS, AND RIAS6 AHD 74= TIONS OF I I SAN JOAOUIN Cot M, prylRCNMI=AL HEALTH DEPART262I. OWNER OR LICENSED AGENT'S SICNATURE CERTIFIES THE FOLIOWINGi •2�[I'SFY ! ! TEAT IN THE ETFPOWYWCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PER90H IN SUCH A PWWM AS TO I gg VUBj^CT TO WORN=,S COMPENSATION LAWS OF CALIFORNIA.' !IFORNIA." CO"RAOR'S HIRING OR b`U9C0NTRAC n1G S20"haun CERTIFIES THS ! ppIdAWING: 'I C}RTIFY THAT IN THE PERFORMANCE THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS 9UWSCr To ! ! WDRIW-s COMPENSATION LAWS OF CALIFORNIA.• 1 T::.,E � c I [�� C7 DATE ILL. -w AF7LICAhT'S SIGNATURE: ! ------------------------------------------- -------------------------------------------------------------- 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. Name7�i i n(�A:car HC•-Ik'—, ,(j (-- _Address Phone#(714-)SZ-2-c-,W