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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENJEC 2 1 2004 <br />304 E WEBER AVE, 3"O FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT' <br />THIS PERMIT EXPIRES 90 DAYS FROM TH APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT _PIPING REP UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+---------------------------------------------------------- <br />M Q ------------------------------ <br />I { EPA SITE #G� W� I PROJECT CONTACT &TELEPHONE # <br />I +-------------- --- -! - ------ ---- - --- - ----1 ------4"-v - �J 3 <br />------ -- - -- <br />F I FACILITY NAME --- -PHONE # ---- -- ---- - --- <br />1 A +--------- -- ---------- <br />1rJ� t------d-�-Cy�i----Q°�� I Gd dZS <br />---- t- ---------------------- --- M --------- <br />C 1 ADDRESS TOO , <br />`� iLmD.7 <br />----------------------------- <br />I L I CROSS STREET T44 ---'-----i <br />1 I +--------------_oa�� <br />--------------------------------------------------------------------------------------' <br />I T I OWNER/OP --------- <br />TOR PONE # <br />i Y i 1 <br />---+-------------------t'---------------------------------------------«-a-z <br />+---- ----------------------' <br />C 1 CONTRACTOR NAME ------------------------------� PHONE # <br />I N I CONTRACTOR ADDRES � I CA LIC # I CLASS c6� <br />T+----------- ---�-- ------------- b <br />I ---- ----- ----- ---- _------- ---------- ------------------ Q - <br />R I INSURER WORK. COMP.# 1 <br />---------------------+------------ <br />C I OTHER INFORMATION I i <br />1 T +----------------------------------------------------------------------------- <br />-------+----------------------------------------1 <br />1 O { 1 PHONE _# <br />1 PHONE It <br />---ill{1111iIITANxI ID{I11iIi{1111' -- ---------------------------------------------------------------- ---------- - <br />I TANK SIZEi CHEMICALS STORED CURRENTLY/PREVIOUSLY i DATE UST INSTALLED <br />I i 39- I OS <br />T i 39- <br />A 1 39- I <br />N 1 39- 1 1 1 1 <br />1 K 1 39- I <br />I 1 <br />1 1 <br />39- <br />I { I 1 <br />I { 39- <br />+-p-i111I11111111 1 II11111111 VIII I 111111 II 11111111 111111111 1111{I{11111I11 III111111111 IIIIIIIIIIIIIII! <br />1 <br />I L { _ APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED <br />I A { (SEE ATTACHMENT WITH CONDITIONS) <br />I N I PLAN REVIEWERS NAME DATE <br />*--'Iil1{III{{1111111111111{1{11{Illllill{1IIIIli 111111111 I11{I11i{1111111{illll111{{Illi{11111{i1111i{{lil{{11111111i1ii1111{{111 <br />1 <br />i APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I <br />I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />i <br />i THAT IN THE PERFORMANCE OF THE WORK F WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I <br />I BECOME SUBJECT TO WORKER'S COMPENSAT ON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I <br />I FOLLOWING: "I CERTIFY THAT IN ORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />I WORKER'S COMPENSATION LAWS F CAL 0 IA." <br />^z - <br />I APPLICANT'S SIGNATURE: C TITLE' <br />I <br />iz <br />+-------------------------------------------------------------------------------------------- ----------------------------.--------+ <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 <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />f4oame-t <br />Signatu <br />EH230038 <br />(revised 1/31/02) <br />1 <br />49hc.( Phone <br />