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SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 304 E WEBER AVE,3RD FLOOR
<br /> STOCKTON,CA 95202
<br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT
<br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW:
<br /> TANK RETROFIT_PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT
<br /> +--- --------------- - ---- ---- ---------------------------------------- +
<br /> EPA SITE # PROJECT CONTACT & TELEPHONE # 5
<br /> ------- r
<br /> F FACILITY NAME PHONE #
<br /> A +----------------------T� -- - - �---pA1/_--ft�n��+-- --- -- --- - --- `�i 6--_M&:337 --------
<br /> C ; ADDRESS -� -__�t n y�L{. l_ L..-L-��
<br /> I +------------------ -- - - -f----- -----------------------------
<br /> L CROSS STREET
<br /> I +--- M 1 ---
<br /> T OWNER/OPERATOR
<br /> ]]]LLL 111 PHONE # ----------------------------
<br /> - - -- ---- -------------------
<br /> Y ' Ni' �' p ----------------------------------------- 1L --3l16--
<br /> T +-CONTRACTOR-NAME--�-k4i
<br /> J_C1 __J1LV V_OI3 _ �1 _ 1 PHONE #
<br /> -----------------
<br /> ; CONTRACTOR ADDRES
<br /> P u C CA LIC # - -- -CLASS A
<br /> - -- --i-- '�-- --- -r(------------------S42-6q-- - - -- --- "1--- ---
<br /> ,
<br /> -- -------- - -
<br /> R ; INSURER ' WORK.COMP.# '
<br /> A --------- -Ty-- - +------------oo�ol�,�_
<br /> C OTHER INFORMATION
<br /> O PHONE #
<br /> ,
<br /> PHONE #
<br /> -----------------------------
<br /> TANK ID # / 1 QTA SIZE CHEMICALS STORIE(�RJRRENTLY/PREVIOUSLY DATE UST INSTALLED
<br /> T ; 39- ;
<br /> A 39- C
<br /> N 39-
<br /> K 39-
<br /> 39-
<br /> 39-
<br /> ' P ,,,,,, �,,, ,,,,,,,,,,,, ,,,,,,,,,,,
<br /> L ; APPROVED _VAPPROVED,WITH CONDITION(S) DISAPPROVED„
<br /> A /� (SEE ATTACHMENT WITH CONDITIONS) p
<br /> N ; PLAN REVIEWERS NAME ��LC.YIA . lid !1,(�] DATE oZ/ 0
<br /> +---,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,„ ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
<br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF
<br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY
<br /> 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
<br /> BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE
<br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO
<br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." V F
<br /> APPLICANT'S SIGNATURE: 4 TITLE `VIS04 Mm"LT, --
<br /> ,
<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 /> /� �Sg51- 1002
<br /> Name &&2[Ta Pend r[ Address'00 D8 X 1 Al�,J) (A Phone #q 16-394-3716
<br /> Signature e'L,
<br /> EH230038 A2.Q_ 0,7,C��-1�l'u v,). Gt
<br /> (revised 1/31/02)
<br /> 1
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