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11130/2004 11:53 2094683433 FIFTH FLOOR PAGE 04 -Eat] SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i pt Iv��NT HEAk.ZH 304 E WEBER AVE,3"8 FLOOR t p �,e STOCKTON,CA 95202 tl�i/"� �� APPLICATION FOR UNOERGROUNDITANK 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 UNDER DISPENSER CONTAINMENT REPAIWRETROFIT +----- -------------------- ------------------- ------------------ ---.-. :---------...------------ ` -------------------------------------------`- -- ( I EPA SITE 0 O !_�( n�_ I-PROJECT CONTACT F< TELEPHONE # a I +----------- ! ---------- --------------`-------------------------------- ------------------ F ._ 1 PACXLITY mme - (C I PH ------- -- i ONE IA r-------------/'�C_ t-Q...- ------------------.--- --- - C I ADDRESS L CROSS STREET -----_ II +--------------------- --- �o-------------------------- I T ( OWNEM/OFERATOR -`----- -`--' Y 1 •h ('� PHONE # � 5� ' ! i I--------`-----------• _------ •------------------------+------------------/--„-(,-�-/----- i C I CONTRACTOR NAME ( , 1 ��__ p�- - 1 PRONE #Q�� _l� 1W_q� I•'1---I 1 0 +----------- ------L--�1 -- - -S r ---- - ----+,------ 3wLJ --------------------------- iN I CONTRACTOR ADDRESS sv 1 • iQ pe 15L �'.- CA LIC # - 15---� CLASS 0142,/7/C..IO C.2) Z,Dg0 Tp..----------- - •� ----------"� - --- _ ... INSURR RA I ------R (��-------- -._ WORK.C1Tl�_#- �� I----------- - - -- - - --- ----- -+---------- -- I C I OTHER XNFORMATION I 1 IT *----------------------------- ----------------------.------- +-------------- OI - PRONru # 1 1 R *----- ----------------------------------------•----------------------'----------------------------------------i ' -�_ - PHONE # I +---1111111111111111I1111i11i1111111----------------------------------•----•--------- - - - ------------------------------------I I I TANK ID # i TANK SIZE i CFI8MXCAL3 5TORED CURRENTLY/PREVIOUSLY j 'DATE UST INSTALL= f I T 1 I 39-H 139- I I i 1 ' i 13139 I I 39- � I 139- 1 I 1 I +---11111! 1111 �IIIIII 1 1il1111111i1111111111111111111111111 i I IIIIiEII P1 I L I APPROVED K APPROVED WITH CONOISIONC00 _ DISAPPROVED I A 2ENT WITH CONDITIONS} 1 N-11111111R1'r1{EIIIIIII 11 111111111HIIIIl ii�H1Tf111iT1� H111 Z�,Cfloc- 1101`1 I H 111 111 I I 1 APPLICANT BUST PERFORM Ay(, WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND RE0CIX.4TXON3 OF 1 SAN JOAQU79 COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT-S SIGNATURE CERTIFIES THE FOLLOW=: •I CERTIFY 1 THAT IN THA; -PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS XSSUM, I SEALL NOT £MBLOY ANY PERSON =N SUCH A MANNER AS TO 1 i SECOM3 8UWZCT TO WORKER'S COMPENSATION LAWS OP CALWORNIA COW=CTOR45 E11AINO OR SUBCONTRACTING SIGNATURE CERTIFIES THE i i FOLLOWING: •I CERTIFY THAT IN TFIP. pERF'Op1•fR1SCE df THE WORK FOR WHICH THIS PERMIT I5 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I i WORM'S COMPENSATION LAWS OP CALIFORNIA.' APPLICANT'S 9I120.Ttni$= � � TITLE �� DA'B'S +--______________________________________-_____ __--____----_-________ ----------------------- -----------------.----- -------- BILLING INFORMATION: Indicate the responsible party to be billed for additional END 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 LAJ C .{ e Qr ry ,Address 30 v%-c,%. . S v 'k. Sr Phone# `t f� Cv Signature EH230038 (revised 1131102) 1 '