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'01/25/2002 1.0:09 20946#3 FIFTH FLOOR • PAGE 02 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE STOCKTON. CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE, 00 NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: _�,_/TANK RETROFIT _PIPING REPAIRiRETROFIT UNDER DISPENSER CONTAINMETNT REPAIRIRETROFIT -.. --- -- - - -- - -- - -- - - --- - --------- --- --- -- -- - - _______________________y, I I EPA SITE # PROJECT CONTACT 6 TELEPHONE # -I ------------------------------ -------- ---•-------------------------------------------------------- 1 F I FACILITY NAME 1 - -- I A ----------------kip. o1L _� ANS{_X27------- - -- - ' PHONE -# C`�3��B 5-_.0� /� p� ^ HONE I ,ADDRESS ..��__X12ti-L L+-_LQ_P_..�4�T�-------- -- - ------------ C --- I ----------- --o-------s cci:� - 1 L I CROSS MEET- - 1 I I ------ --- PIC_PC) l`T_J1 1 T OWNER/OPERATOR I PHONE # ' Y _5r�9P0_A_..W o 1�1 l P• I� - :- -- ---- Q-) X35 ` 0461 - ---------------- -- ----- - ----------------- c I CONTRACTOR NAME >✓-[j-L _ ��`�` F�►�.� ---1 G - --- - - • -- - --- � _PxoNE-k � 2 � _ � � — - 7 5 C� 0 y_____________________ - r1__ N ( CON?RACTOR ADDRESS �°'�'(I L-r'E—f•--�_ I _CA - LIC . $_ ''i Zu � Ci ^� _ I -CLASS_ R I INSURER ^ 1 WORK•COMP.41 C 1 OTEISR INFORMATION - ---- --- - ---------- - - T---------------------�--A� - - - ��KLf, _------------------------------I - D / Q Q R-----------------------------------------------------------------------• I PHONE # �9'z G (OO -1 II Aid- - ------------------ _ I _I -PHONE # •--I1111111111111111IIIIIIIIIIIIIII--------------------------------i---------------•- ____--_-__-_•-.- .-_______-_-____-_ I I! TANK ID # I TANK SIZE i CHCMICALS STORED CURRENTLY/PREVIOU6LY DATF. UST INSTALLED 39- IT 39- I 1 1 ij : A I 39- N I 39- I l55 I a n I I K 1 39- I 39- 1. i 139- I i-p-�I1I1. i I IIIIIIIII inIII1III 1111 11 111H 1 1!11111 ,111 I IIIIII11 MI 11111111111 1111 I I I A APPROVED APPP.OVED WITH COIaDITION(S) DISAPPROVED 1 (SEE ATTACHMENT WITH CONDITIONS) I I N PLAN REVIEWERS NAME �/bGw. J DATE r--- IIIIIIIIIIIIIII11111 I IIIIIIIIilllllllllll II111111111111111111 I 1111111 � I II IIIIIIIIIIIIIIII APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE wITI{ SAN JOAQUIN COUNTY OnnINANC65, STATE LAWS, AND RULES AND RSOUTATIONS OF 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMFIRT. OWNER OR LICENSED ACCOT-S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 1 THAT LN THE VBRFCP24MCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, Y SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR -8 HIRING OR SUBCONTRACTING SIGNATURE CERTIFIMTHE FOLLOWING: "I CERTIFY THAT IN THE PERPORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CAL FORNIA." , i 1 i ! AFPLLCANT'S SIGNATURE: TITLE fl, DATE -------------------------------- - ---------------•----------------- &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 ' �T- rAddress 614-7 51 Phone number �v6L I GA q4505f3 Signature Z14 4f, EH230038 1 JAN 25.'02 9:10 2094683433 PAGE.002