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SAN JOAQUIN COUNTY ° ECENED ENVIRONMENTAL HEALTH DEPARTMEN _ 304 E WEBER AVE,3"D FLOOR O C T Y 412005 STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT ENVIRONNIEN I HEALTH X �I�2XICES THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PE BLOW: _TANK RETROFIT Y PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT -------------------------------------------- + I___� EPA SITE-#- ---- - ------------------------------I PROJECT CONTACT & TELEPHONE # i>" yElzk.E-S-I-(7)4) ------------------------------v---j -------------- { F I FACILITY NAME R e0 �o O V PHONE # I ---- -------------------------I--------------------------------------i I C I ADDRESS g5__ -sr--- u r s _ A v6.---�----L4 4 Plop ------------------------------------� II +------------------- L I CROSS STREET --------------i -- ---------------------I ---------------------------------------------- -- T I OWNER/OPERATOR +- -- Y I BP I�IESi Co PQ o--liGTS L�. ------------------- I PHONE # --------------------- C I CONTRACTOR NAME T/�r T �v 1�A/"��L Sys l r/�{6 I PHONE TAIr -------------------------------------------- p--------------a------------f-------------I I 0 + - - - CA LIC # 98 i CLASSA A58 A47-6 6LI D N I CONTRACTOR ADDRESS ��flv3 til./UEv�I.LE s,: .o -- ------------- -------------------------------------I IT +----------------------------- I R I INSURER TRA✓EL-6fL5 I I�IbE�w IrV 60- D� &NU6e_-na -r wo—Com" y„ 1-- IA I-------------------------------------------------------- ------i - }g - C I OTHER INFORMATION --+----------------------------------------I l o { I PHONE # I ----------------------i----------------------------------------i PHONE # I + --------------1111111111111111{IIIIIIIIIIIIIII ------------------------------------------------------------{ TANK ID # i TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED I I I I i 39- L T 1 39- A 1 39 9-AI39 I I N 139- K 39 9-KI39 39-39-PI L I APPROVED ./APPROVED WITH CONDITION(S)4(_ DISAPPROVED A I (SEE ATTACHMENT WITH CONDITIONS) 1 N I PLAN REVIEWERS NAME DATE +___Illllllllllilllll IIIII II III 1111 II IIIIII1111{IIIIIIIIIIIIIIIIIIIIIIIIIillllllillllllli ILII IIIIIIIillllll111111 I I 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 I I THAT IN THE MANNER AS TO i PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MAN BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I I � 2 I I APPLICANT'S SIGNATURE: ' L TITLE . � 1� DATE 10-1J I - ----------- ------------------------------------- -----+ oic- BILLING INFORMATION: 3. �-saa ras�•v.,� ....�� 'R��.r�G s>�� .�s-r �� .c,c.. � 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. Name TAI i E?.IyRo.[NC'�yeylc, Address 18&3 �J NEyiLI.E Ste. 1 Q Phone#(`7i�)SZ 5`/5 Mks 1