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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: ____TANK RETROFIT -V'.PIPING REPAIR/RETROFIT ____UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ----------------------------------------------------------------------------------------------------------------------------------- EPA. SITE k 1 PROJECT TELEPHONE k ,(lO ___~___ (CONTACTS � PHONE F: ___________________________________________ -_,___________________________-_r__� — ' - _______I".'=tea_ _ L CROSS STREET _______________________________________________ T OW -,FR, OPERATOR I PHONE k 1 ______ _____- _______________________/ _ s.i; r ---�-- - --- te�•� CO??i^icR NAME ----------------------- PHONE* ------- -- -�U�C '-- ---- ----�,-"1- ADDRESS CA LIC k `5 -- ----- __SLLS-------------- S.�- WORK.COMP.k c �% - _ -;--_-- R-INF^vPt!=.T_ZON ---------------------------------------------------------------------------------------------------------------------- . ------------------- --------- ---- - ------------------ ---------------------------------- PHONE . k ---------------- - - ------ - ------- i PHONE k TANK ID k TANK SIZE CHEMICALS STORED CURRENTLY/ PREVIOUSLY .,r.=E US.=NSTALLED 39- 39- A 39- 1: 39- K 39- 39- 39- 1 i --__ I1II I I i 11111 1 III II 1111 11 lil Illilil I1(III I 1111 I Illillll ll�'I Illl 11 1111111 11 111 111111 llllllllill 11 Illilll lllil1 V III 1 I I VIII L APPROVEEDD�77f X APPROVED WITH CONDITION(S)* DISAPPROVED �� (SEE ATTACHMENT WITH CONDITIONS) S-/^ /e, , -_N PLAN REVIEWERS NAME �_ OZ�� aY 6/ II 11111 I11 lill;l I'1 11 1 1111 X11111 I I11,II 11111111111 II Ii 11 111 11 11 111 llilllli ills II 111 1111 I Ill I1111111IIII 11111. .x111111 II n_ci.ICAh. MUST PERFORTI ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATICNS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOri ING: = CERTIFY ' 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 1 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE= CERTIF=ES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SLnJECT TO WORKER'S CON?E'SATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: �/ •' ys 7� TITLE __ I. Arr�^� A��^ �� r dr+s�, S-�s�•.. BILLING INFORMATION: O cJ�n ".6 sPPh 6VLkVt bl-f -rig/ 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_Phone #-4 Sic =fit t3 S Esc. C SS- t -�;l