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5AN JUAWUIN t:UUN 1 Y EMVIRONMENTAL 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: ��PhawS �TANXETROFIT PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ---------------------------------------------------------------------------------------------------- ---------------------------- I I EPA SITE # I PROJECT CONTACT & TELEPHONE #hgi,3z L7lanlnc (RNi.' 92$•313.177001 i +-------------------�------------------------------------------------------- -----------------------------------------------1 i F I FACILITY NAME 'S[•Z� G' 1 4i7 G .bn pradUcfis Cp. I PHONE # I .. IA+--- -----------------------------I C I ADDRESS 12 3 4 Ave. ., M 9 r%+e_41 . '15-15 Co 11 +-----------------------------------------------------------------------------------------------------------------------------I I L I cRoss sxRE>:r 15pr cakCI b I I ------------------------------------------------------------------------------------------------------------------------------ I OWNWQPBRMM Y i chevron Products Co. (Attn: DaVW Lyons i PHONE # (q25�$42-438 I C I axnuc=mmjavid-5,e, Construction , In c. i 530, (022- 1982 I I0 +---------------------------------------------�-^-------- -------------------------------PH®ONE------------------j--------------i N I CONTRACTOR ADDRESS -4 4 01 5.Dn j 2 A.-OU rt,,�tVA It I CA LIC# 755 6-1 6 I mus A HAM. IT+-------- --------------------------------------------------------------------------------------------------------------------I R I IN=RER `jl12t6 Comrens2ti6n Insurance Fuhd I w0RK-Cam.# 27B-2003 I IA I------------------------------------------------------------------------------------+----------------------------------------I I C I OTHER nipau=w 1 I IT-------------------------------------------------------------------------------------+----------------------------------------I 101 iPHONE # i IR+------------------------------------------------------------------------------------+----------------------------------------I I I I PHONE # 1 1----------------------------------------------------------------------------------------------I I I TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE VST INSTALLED I I 139- O1 i W,00.0 I Me- UMI. ( 2txk0! I1 I T 1 39- 02- ( I S ,ov® I ?rCwe. Un I. IA139- I I I I N 1 39- K 39- 39-39- +---IIII11111IIIIIIIIIIiII1111111111111111111111111I Illllllllllilllllllllllllllilllllllllilllllilllllllill IIII11111IIillllillilllil IPI I I L I APPROVED _APPROVED WITH CONDITION(S) _DISAPPROVED I A 1 s (SEE WITH CONDITIONS) 1 I Pr I PLAN REVIEMM WS DATE +---I1111i1t111111111t111�1111111111ti11111111111111111111'111111111111111tllllllllllllllllillllllllllfl!'IIII1111111111111111111t11 I I APPLICANT MUST PERFORM ALL woRK n;ACCORDANCE WITH SAN JOAQ= COUNTY OROnva ES, STATE LAWS, AND RULES AND RECUJLATIONS of i I SAN JOAamN Comm, mmn=aN=HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY I i THAT IN TEE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 1 1 BECObM SUBJECT TO c -S ENSATIOT LAWS OF CALIFORNIA.- CONMMC=1S ==ORSUBCONTRftCTING SIGNATORE CERTIFIES THE 1 I POLLOWM. -I CERTIFY THAT IN THE PERFORN4INCE OF TIM WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORKER'S COMPENSATION LAWS OF CALIFORNIA.- I I I jAPPLICANT'S SIGNATURE: TITLE l'3m -6r t hs4rOn DATE I ofn�o>�4W.,Ine_. 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 R14 C?_-�Ilrl �®uP, Ane-Address 1540 Arnold Dr: iI(� M21rfenetPhone# 925-313-1700 G Signatur ^�`""'� rlt for ®� 84553 exp toy EH230038 1 (rPviGPr1 1/11W)