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• SAN JOAQUIN COUNTY 0 ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3R0 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 X UNDER DISPENSER CONTAINMENT REPAIRiR6ZAAF T- +------------------------------------------------------------------------------------- - + ------------------ ----- I I EPA SITE #PROJECT CONTACT -& TELEPHONE -# ----- F I FACILITY NAME I PHONE # I ----- ------------------------ I C 1 ADDRESS �--- *" •"'� ------------------------------------- L I CROSS STREET I+_____________________________________________________________________________________________________________________________I T T I OWNER/OPERATOR i PHONE # Y ___+_____________________/_/_______________,-_______i____�_i_ff_____`_f____________�________________+__l/_____L_aJ__i__�__j_ ______ C I CONTRACTOR NAME PHONE #y�y-------------------- CALL, 1090 /o T_ 0/ C --- SKI ------------------ --- CALIC #rCLASSN I CONTRACTOR ADRES r __ G�O�--_i T------------ry��& R INSURER WORK.- __/�J1'�_______________________________________+_-----A _______�___ III C I OTHER INFORMATION I I T+____________________________________________________________________________________+________________________________________I 0 I I PHONE # I R+_-.._________________________________________________________________________________+________________________________________I I I PHONE # + Illiliiiillllllllilllili U illiil----------------------------------------------------------------------------------------------I I TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I I 1 39- I I I I T T 139- I T A 139- T N I 39- K 139- I I I I 139- I { I I 39- + iliiiillliililliiilliililiiillillilllliiiillllliillilllllillllllllllll M I lllllllllllllilllliillilillliiiilllillllll IPI I L i APPROVED APPROVED WITH CONDITIONS) DISAPPROVED A I (SEE ATTACHMENT WITH CONDITIONS) I N j PLAN REVIEWERS NAME DATE i iii i ill I M 11111111 i iii 1111111111111111111111111111111111 i iiiiiiliiiii H H! iii 1111111111111111 i i i 11111111111 HIM! iii I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE ,LAWS, AND RULES AND REGULATIONS OF I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I I 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 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 I I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I i I f APPLICANT'S SIGNATURE: TITLE 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��_--Address _ _—Ct1 _ Phone 1