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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3iiD 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 DISPENSER CONTAINMENT REPAIR/RETROFIT +--------------------------------------------------------------------------------------------------------------------------------+ EPA SITE # i PROJECT CONTACT & TELEPHONE # ---------------------------------------------------- ._-___________-__________-______________-__________ ______________________i F j FACILITY NAME1 PHONE --�---- �- ---- '-------#- - C i ADDRESS �I I + - - - (-- -- - - - 1 -- f ' P 1 ; - -'----- -- -------- L i CROSS STREET \ 1 I +_______________________________________ ___ ___ ________ _________________________________________________________________I T 1 OWNER/OPERATOR PHONE # � j -Y ' --- D_�'��-- - - 1 +-----------------------------------------'-------------------------------------- I (/''�� $' ' P /I C +CONTRACTOR NAME-- - -- ---.�--- --L-'\i �- - --- ---- - -'--- ---- --- 1-- --- ----'------ WDS!� 2 �! / N i CONTRACTOR ADDRESS - IC CLASS n1: .lhl----------- ---- -I R 1 INSURER 1 WORK. COMP.# A i___________ • I C_�_ _ ____ _______________________+_________________________ _____________ ______ __ _ C OTHER INFORMATION IT_______________________________________________________+___________-____________________________1 0 PHONE # __________________.}______..___-_______________-__-__________1 PHONE # IIIIIIIII II III II IIIIIIII II II ItI______________________________________________________________________________________________i +___IIIII111111111111111111111111111 j TANK ID # i ® TANK SIZE 1 CHEMI STORED ENTLY/PREVIOUSLY DATE UST INSTALLED 39- P�� 1.1qcd. 1 t - - T 1 39- A j 39- N i 39- K i 39- 39- 39- +___IIIIIIIIIIIIIIIIIIIII111111111111111111111 II1111111111111111111 V III II 1111111111111111II1111111111; 11111 II II IIII IIIII1111 II IIIIIIIIIIIIII1111111111II IIIIIIIIIIIIIII11111111111111111111111�1111111 VIII IIIIIII11111111111111111 II V III IIIIII111111111111 P L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED j A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE +---I I11111111111111111I�III II illtlllll llllllllllll111111111111111111 �I III 1111111 VIII It IIIIIIII IIIIIIIIIIII11111111111111111111111 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 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 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 COMPENSATION LAWS OF CALIFORNIA." I 1 I 1 I 1 td I APPLICANT'S SIGNATURE: TITLE aAjjLjZ �DATE I I +_________________________________________________________________________________________________________________________________+ BILLING INFORMATION: THAT IN THE F*Tu45t• 7 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__ e _ Y -I _46DAddressC_ _ t _ OL __Phone #L �91M/ 7tC(,e7 C1+ r 1