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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3"0 FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WP.ITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +------------------------------------------------------------------------------------------------------------- - - - ' 1 � EPA SITE # PROJECT CONTACT S. TELEPHONE '# +_____________________'__-__.___-_____._-----_______________--_-____-__________-_____-______' p G ______1 F FACILITY NAME hL-- O �� PHONE - Cl ( c�J y O -------n------------- C i ADDRESS s LVL IIS C. /7✓ L l4 /2 I ------- I --- - - - -- -_- - ___-___-'---------- ------------------------------------- L ; CROSS STREET --------- 1 +---------------- { I T OWNER/OPERATOR ---�----------------------------------------i I Y1 ( P L-)t T CO- 5 7- LLC l- PHONE # /d/Z,O O -- C i CONTRACTOR NAME - sW l 7 --S'--s——— -t-----' ---- � I PHONE � ------------------ � ,0 + c ------—--------------------—-------——------ ( � -5 - �--- — — S _P�_---N I CONTRACTOR ADDRESS- � ` CA LIC # � CLASS + -----T D _ _ - ------------------------------{ R I INSURER /� �/ �/ _ / �1 G I A I --- - �2f� <X--- SC- --fif VTC I WORK.COMP.# �l_1 Z C i OTHER INFORMATION 1 - -- - -- 0-----I T +__________________________________ ------------------- ------ ' R t-------- -C�'L ---r-- Lv le -------/�2 f -�'-u-�---------------------' q_r�_j�_ _5 I PHONE # +--- 111111 1 1111111111 III II I 1 PHONE_$__ �111111IIII� 1111111111IIIIIIIIIi----------TANK SIZE -------CHEMICALS STORED CU1 TANK ID # CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T 39- I �9/�S� / 1 � I A I 39- I I N 39- K 39- 39-, 9-39; 1 1 I 39; +---:lillll I II it II I I I 1111 111 111 II I 1111 11 II II 1 1 tll 1111 III I 111111 111 11111 II 1 IIII I 11111 �111111 � 1 IIIIIIIIIIIIIIIIIIIIIIIIIIIIII � II11111111 � 11 �11 � 11{� IIIIIIIIII � �I � IIIIIIIII � III�I� IIIIIIIIIIIIIII11111111111 ' PI I 1 L _ APPROVED APPROVED WITH CONDITIONS) DISAPPROVED ' 1 SEE ATTACHMENT WITH CONDITIONS) A DATE N � PLAN REVIEWERS NAME 1I11v i ii 111111 i i 1111111111111 111,Ii � iiiii �iiii �iiiiiiii{�i�iiiliiiiiiiii I 1 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 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 IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." 1 , 1 1 1 I 1 1 / �7 ( /^_ APPLICANT'S SIGNATURE: , _ A � TITLE _1�� I_aC.�%WATE z ' I ------------------------------------------------------------------------------------------------- I 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. Name ' 7-ac-i 0(L L/ Address 32- 1�3 L-Uz ctom; A9A Phone # 5-6-'�j'1096' Signature/- EH230038 Q00-Ce-A G lint KCAL df-te&v- WCLS ft�nfss-ed (revised 1/31/02) -�1r1(�'1'Dy� �rpl �a � � , JAN 0 6 2003 LNVllvivivlc:f'�s rr!tii.1 1 PERMIT/SERVICES