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• 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3RD FLOOR STOCKTON, CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT 90 DAYS THIS PERMI�TA�SR RDFIT� IPING REPOAIR/R�ROF�NDER�PENSER CONTAINMENT INDICATE EPAIR/RETRPERMIT OTYPE BELOW: FIT +----------------------------------- - - /f�!��-- - - /// -------- + I PROJECT CONTACT & TELEPHONE # tif�1� __ �ir EPA SITE # tif/f5 /11 CCC- F FACILITY NAME r-_ �_ PHONE # I + ADDRESS- L ; CROSS STREET I+---------------------------------------------------------------------------------------------------------------------------' T OWNER/OPERATOR ' PHONE # , Y ---+--------------- -- --- ----------------------+-------- ----------- C I CONTRACTOR NAME PHONE o+------------------ - -- - -----L - ----- - ----- :-AU -- N I CONTRACTOR ADDRESS / ',/Q� CA LIC _# �� CLASS IT +_________ __L _ _ Q _ _ __________________________ R IN ---------- I A-------- - -----------------------------------------------------+---------------------------- ------ ---- I C OTHER INF ION O PHONE # R+____________________________________________________________________________________+_________________---___-___--_________--� PHONE # ---------------------------------------------------------------------------------------------- TANK ID # TANK SIZEC��OR� CURRENTLY/PREVIOUSLYCURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T 39- A 39- N 39- K 39- 39- 39- + ---II„ „ IIII1111 'Illll.... l 111111 11 11 „ ;IIIIIIII „ , , , P L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWER ��I,J DATE a b „ 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 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." n APPLICANT'S SIGNATURE: TITLE DATE +------------------------ --- - ------------------------------------------------------------------+ 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 datq below( Name -,O� Address � DdA Phone S7 Y Signature EH230038 (revised 1/31/02)