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• t 11 • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, r 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 I--------------------------------------------- - ----- --------------------------------------------------------- 0 - - ----I -- ---- ------- -- ---- --- --------- I F I FACILITY NAME t I PHONE # IA +------- -----------5 -1 ----►--�-� ----- ------ w----------------------------��°3_----------------------- C I ADDRESS 7 1 I +------------- --[-- -------f-r �-------------- ------- - _- �- ----� Cy -=-------1 5 7 -- - ----------------------I I L I CROSS STREET 1 �! --------5 1d ' T ( OWNER/OPERATOR I PHONE # ' ---------------------- _ I----- - G�-s - 1 a5� 66 _ - I ---+- - ----- - - + - - C I CONTRACTOR NAME J I `fie ( - -----� ��-- ---- _I--# - I IO ---------------------------------------- N ----------------------------------------------------------I N I CONTRACTOR ADDRESS r I CA LIC # I CLASS I IT +----------------------------------- - --------- --7 R ; INSURER ---� WORK.COMP.# IA I------------------------------------------------------------------------------------+----------------------------------------I C I OTHER INFORMATION I I IT +-------------------------------------------------.----------------------------------+- 1 0 1 1 PHONE # I IR+------------------------------------------------------------------------------------+----------------------------------------I I I I PHONE # +---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII----------------------------------------------------------------------------------------------I I I TANK ID I TANK SIZEI CHEMI�s STORED TTTY/PREVIOUSLY I DATF UST INSTALLED 1 39- r 1�l, C&C, I&I/ �� I Ig94 I I T 1 39-1361 r(45�I 1 ) . Ly 00 _I._4 I_ ! A 139- - I 4 _I l I I I r K � I I 139-_ � I _I I I I 139- I 139- XPPROVED IIIIIIIIIII 1111111111111Hill IIIIIII1111111111111111:1111i111111i1 PL I APPROVED WITH CONDITION ) _ DISAPPROVED I A I (SEE I S) N I PLAN REVIEWERS DATE _I +---IIIIIIII{IIIIIIIIIIIIIIIII I I III 11111111 1111111 I III II{IIIII1111{IIIIIIIIII { III IIIIIIIII II�IIIIII I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COMM, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I PERFORMANCE OF THE FORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I I 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 COMPENSATION LAWS OF CALIFORNIA." I I I I I (A4L,-T fat SAj; ,L)/� APPLICANT'S SIGNATURE: TITLE 701*60� RO DATE7-14031 +--------------------------------'�Nt---�--5�_�1_--��1- Pro ------------------------------------' BILLING INFORMATION: THAT IN THE 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 l t�iSKc�Address 'o( lir l7� Phone #/� &3l 360X L Aav,tr Fvy2-, 6►PvLt,- 1