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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3RD 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: _r_TANK RETROFIT __✓__PIPING REPAIR/RETROFIT _L,-'GNDER DISPENSER CONTAINMENT REPAIR/RETROFIT� --------------------------------------------------- I I EPA SITE # PROJECT CONTACT & TELEPHONE # / ° 1L- µ"� —a� 9-14- --------------------------------- -14- -----------------•-.•�—�----- �--- -- � ---- - - •� ------------------------ - I +------------------ `' g I PHONE # (2o=��asCe--4o4O'--'-I F I FACILITY NAME - C��'CA%��________________________________________________ rjTc� C I ADDRESS !� — S'bc/_ ��,_ v�---,-i�-e----------------------------------I I L I CROSS STREET4 --------- I +-------------- --- I PHONE # T I OWNER/OPERATOR Y I ------------------------------ i-i4�tc - e---------------------------------------------------------------PHONE ------------------------------------ C I CONTRACTOR NAME i ,y, I PHONE # ---------------------------------- I AtJ�ll I I 0 +____________ I CA LIC # � O � I CLASS I N I CONTRACTOR ADDRESS -- ------'-------'I T +___SURE_____ _____________________________+ WORK COMP.# ---- ZZgOZ��, I R INSURER �`�� l 15., n n. IS L� �1�IG 1 I C I OTHER INFORMATION I PHONE # I O I ________i R+____________________________________________________________________________________i PHONE # I _________________________ I___________________________________________________________________I IIIIIIII IIII +---Ililililil1111I11ii I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLE TANK ID # D I I I I 39_ Q11 I %9 C.16GC P1 h,l!2 1�_'7ur7 I A?ii_IIIC TTI 39_ j� I !�, r:- Cor 'AW h"t.WT I r4jE�� I I I A I 39_ fLC� �I , �.. r I I INI39- I K 139- 139- 9-I39- I I I I I 139- I " " " " " " 'Illllllllllllllllllll + IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII]H IIIIII IIIIIIIIIIII11111111111111 IIIII II I IPI I L I APPROVED APPROVED TH CONDITION(S) _ DISAPPROVEDT A I NAME ( E TTA CONDITIONS) I DATE I N I PLAN REVIEWERS + 1111111111111111111111111 11111111 I IIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII I II IIIII IIIIIIIIII I' I 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 PERFORMANCE OF THE WORK 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 I COMPENSATION LAWS OF CALIFORNIA." {II - TITLE DATE APPLICANT'S SIGNATURE: f __________ _�� D3 III I BILLING INFORMATION: THAT IN THE WORKER'S 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. _----Phone