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SAN JOAQUIN COUNTY EN*ONMENTAL HEALTH DE%RTMENT 304 E WEBER AVE,3M 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: �Phases -C<-TANK RETROFIT --PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +---------------------------------------------------------------------------------------------------------------------------------+ 1 1 EPA SITE #_________________________________I_PROJECT-CONTACT &-TELEPHONE #hsip c-pianin0 (RR►,) `12s.st!,.4j7ao I _ _ _ _ _________________________________________________________ 'R I F I FACILITY NAME 2 0-1 7& 1 /�rbn T rodV"s CO.. I PHONE # IA +-------------- - - ---------------------------------------------------------------------------------------------------------- C I ADDRESS i 1103 S. M-a rn St. Hzni'eG a 9533 - I II +-----------------------------------------------------------------------------------------------------------------------------I I L I CROSS STREET [jjSU?0'^ Rldgt Dr. II +-----------------------------------------------------------------------------------------------------------------------------I I Y i GWNER/6?Hi PBR ) 1 PHONE # I Chevron flroducts Co. Ati'n: David Lv ons 1 (125)8342-4367 I c I CONTRACTOR NAME Savidge, Construction , Inc. I PHONE # (53o) 622- 1982 IO +-----------------------------------------------------------------------------------------------------------------------------I I N I CONTRACTOR ADDRESS .4401 5Dnj2 COU rt-,PlWrV111ti CA LIC # 75554$ 1 CLASS ,4 , HA7.. I T +-----------------------------—----------------------------------------------------------------------------------------------1 1 R ; INSURER Stot'e (.0M CTS2t1°rt Insurance Fuad I woRK.cOMP.# 2 7 3-2003 1 IA I------------------------------------------------------------------------------------+----------------------------------------I C I OTHER INFORMATION I I IT +------------------------------------------------------------------------------------+----------------------------------------I 0 1 1 PHONE # I IR +-------------------------------------------------------------------------------=----+---------------------------------------I I i I PHONE # { +---111111111111{IIIIIIIIIIIIIIIIIII----------------------------------------------------------------------------------------------I I I TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I I I 39- 01 1 12,000 I reA- un1. 1992 { T 139- 02 1 12,000 I in Lind+ 1 X912 { A I 39- 03 1 t2_oOD I prem. uy+l• I 1812 IN139- I I I I IK139- 39- 39-_ 9-39-39- I I I f +-__1111{lllllllllllllilllllllllllllllllllllllllllllllllllillllllllllllllllllllllillllllllllllllllllllllllllllllilllllll{Illillllll IPI 1 L I _APPROVED APPROVED WITH CONDITION(S) _DISAPPROVED I 1 A I (SEE ATTACHMENT WI YMITIONS) /J 1 I N I PLAN REVIEWERS NAME 0G�.../+L/ /L�� ATE (/ 1 +___lllllllllllllllllllllllh�`11111 111i11111111111111111ilillll IIII111111111111111111111III 111111111 11111 I11111111i11 m III i I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I 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 I I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA." I I I APPLICANT'S SIGNATURE: �I W TITLE A3w1 -br Cha/rOn DATE 7/Z I I/Q+ I oRW L 11 n OL40.1 me. 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_RHL Df.)1 &roupIn'-Address 1_240 Arnold Or. 0110 1121efinet phone#U57313-1700 — - 84553 ex's lob Signatur ^,"""� ^-f fO�G�`�°'^__ EH230038 1 (revised 1/31/02)