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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3RD 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 1 1 II I ----- ----------�-----�---2---- i C-PROJECT O,JE/�T-/�-CCOONNTTA-C-T-----Tj-ELEP_H_O-E- #EPA SITE # IqzV T F� +-------------( Q-QQ -------------------- --------------------------- F --------------------------F FACILITY NAME iPHON-E--(#-�-+-Z,--�-"-T�IA GA ------------------------------- C _- --------- - ------'3-- -�--^ i_i 7 ------ I I ADDRESS 40 � W jL .�- I - fv,i��----- '1 ----------- ------------------------------------------------------------ L ------------------------------------------------i 1 L I CROSS STREET I +-------------- -- ----------------------------------------------------------------------------------------------- --------- --- -- I T i OWNER/OPERATOR `` ff 1 PHONE # _ -"-:------C'i:RE_Er�--- (__ c�-- -��o� �N�-----------------------I-�S1`� ��-- -�Z=©0------- I C I CONTRACTOR NAME �� l I PHONE # I 1 0 +-------------- �� --' J_ �.V 1 1 -------- -----------CA LIC-#--------- -------i------------ 1 I -14 Z4 (V(0 CLASS N CONTRACTOR ADDRESS /'J"� �r' ✓.//'� 1 I ------------------------------------ I N Y�-��L�� { , ��a� WORK.COMP.# C ►11 R I INSURER �+` �' �J� A i--------------------------------------------- --------------------------------------- --- ---------------------- ----------------+----------------------------------------i C I OTHER INFORMATION 1 T +------------------------------------------------------------------------------------+------- -------- -- ---- ---- ( i 1 0 1 1 PHONE "'{1 6)(4 1 l 1 R +---------------------------------------`--------------------------------------------+---------C -- - -------- PHONE -PHONE # I I 1111111 I I I I V III II I ------'-------------------------------'------------------------------- ---------- ----------I +---I III IIIIIIIIIII IIII 1111111 111111 TANK ID # 1 ANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED1 39- I I`-�� I�0 I F_ E I T I 39- 11 TI L� I A i 39" I I N i 39-_ I 1 K i 39- i 1 39- i 1 +-- ii3iiil 'li1 7T,I1111111111111111111iiili 111111111111iiiiiiiiiii P 1 L 1 _ APPROVED _ APPROVED WITH C ITION(S) _ DISAPPROVED A i (SEE AT W ITIONS) 1 N 1 PLAN REVIEWERS NAME vQ!-*.Z\S ~ DATE "C +---IIIIIIIII111II III II II 11111111111111111111 it III II111111 11 II II11 IIII I IIII1111111111111111111IIIIIIII II II III VIII III IIIIII I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY IN :E , STATE LAWS, AND RULES AND REGULATIONS OF I I 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED IS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 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 I I 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA." .� TITLE DATE, ✓? D+ APPLICANT'S SIGNATURE:` " ' w-mm,.""` ----------------------------------------------------------- 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 i,,t' t1 h� �� AddressT V3(5 X 66 Phone # �-- Signaturm EH230038 (revised 1/31/02) 1