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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3RD FLOOR <br /> STOCKTON,CA 95202 <br /> C, <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 RETROFITREPAIR/RETROFIT ___UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> ---------------------- <br /> ------------------------------------------ ----7------------------------------------ <br /> EPA <br /> ----------- ------------+EPA SITE # PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME C i PHONE # <br /> ��------------------------- --- 1 -7- <br /> I <br /> C i ADDRESS •�7 _� ��/7 �/ / <br /> 1 <br /> L1 CROSS STREET <br /> I +--------------- K �1 - - _ ------------------------------ <br /> T OWNER/OPERATOR �� I jr�/�.�•'S /i(C� PHONE # <br /> Y yo Eox P4CC.o-Xd? a:so <br /> --+---------------- --- <br /> � <br /> j __ _, __ _____________________+________________________________________ <br /> C i CONTRACTOR NAME ­_� (� I PHONE # <br /> N 1 CONTRACTOR ADDRESS 1 CA LIC # 1 CLASS j <br /> t ______ ___________________________________________________________________________1 <br /> R INSURER i WORK.COMP.# <br /> I____________________________________________________________ <br /> C OTHER INFORMATION <br /> T +____________________________________________________________________________________+________________________________________i <br /> O i i PHONE # <br /> ------------`-------------------------+-----------------------------------1 <br /> PHONE # j <br /> +___I1111111111111111111111111111111______________________________________________________________________________________________1 <br /> 1111111 IIIII11111111111111111111 I <br /> TANK ID # NK I SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE STALLED <br /> I �TyA.� <br /> cl <br /> T 394 i c)000 <br /> A 39-.-'3 i /Q LTD C) <br /> N j 39- j <br /> K i 39- <br /> 39- <br /> 39_ <br /> +___111111111111111111 X111111111�1111111111111111111111111111111111111111111111111111111 11111111111111111 III 11 III11111111111111 <br /> II1111111111111111 111111111 II 111111111111111111111 I11111111111111111!I11111111111 11111111111111111 III II 111111 II II 1111111 <br /> P <br /> L APPRO _APPR WITH CONDITION(S) DISAPPROVED <br /> A i EE ATTA WITH CONDITIONS) / <br /> N PLAN REVIEWERS NAME DATE {I <br /> iii ii illi iiii i 1111111;iii ii ii iii i..... iiiiiiiii iiii ii 11 m iiiii iiii i ii <br /> I 1 <br /> 1 1 <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 THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF 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 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO i WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> 1 <br /> 1 <br /> r) I <br /> APPLICANT'S SIGNATURE: TITLEP (� %��/ DATE`� �� <br /> 1 <br /> 1 1 <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name ---Address _ __Phone#__�______ <br /> 1 <br />