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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3"D 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 _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +----------------------- ------------------------------------------------------------------------ --------- + ca�9s i PROJECT CONTACT 6 TELEPHONE # me it.) gOWF-4J _914"j- '$?9 I EPA SITE # r 4�j`514 -------------------------------------------------------------- 1 +----------- ' PHONE_# 2 F I FACILITY NAME ��- ��`� ' li - - - 7�EYEN--- � _'- - I A +--- `, .�.,.y C 1 ADDRESS 4�Z?_�fEY/N�1Q_ �"�TT271J_ �!� JC7_i++� 1 I + - ---- -- -- ► - - -- 1 L 1 CROSS STREETNE ��QcK �S'f�L1 ---------------- ' T 1 OWNER/00~0644- PHONE # 1 1 Y I B�a N/ 7-6�/fiN I Na. 1 tag 47-9-,9416140 ------------------------------------------------ -- ---- - �, # Ca--sT notJ r 1 PHONE # 760 ?-- ^ r 20 C I CONTRACTOR NAME M 1'r ENG i iEEi� #- C ' 0 +--------------------- I CLAS I N 1 CONTRACTOR ADDRESS �5,, I CA LIC # 72339 -----'__--' loStePAEw�oou A'IFGa Oe ±Ns,n�+4A-�-- - r 1 T -------------------------- - --- ��t/1� I WORK.COMP.# 155 R I INSURER SIrA r. :rFtr /�Allo?l4_l�.lS A&q4 Fv1J� �p I I sc ----------'�--'Q-"��--------- I 1 C 1 OTHER INFORMATION +----------------------------------------i 1 T + -----------------------------------------=---------------------------- ------1 PHONE # 01 1 IR +------------------------------------------------------------------------------------------- 1 1 PHONE # II -------------------------------------------i 1111IIII " II' Ill"1' 111111111111 ------------------------------------- ------------- +---1111 11 1 11 1 1 11111 1 TANK SIZE i CHEMICALS STORED CURRENTLY/P%0A G#' � DATE UST INSTALLED I TANK I # 1 -1 39- AD. d7 I mood 4Ai I uN o�� OfflVV&t�JE _I to/9a 1 T 1 3 9- O i�0,dPd%► 4�f. I [lA/I.EI�DBD X171.IA/d� /o S I I A ' 39- I I I II N i 39- ' 1 I K 39- 39- 1 I i 39- I 1 +-__I IIII 111111 1111111 II 11111111111111 1111II111111111IIII1111IIIII IIIIIII1111IIIIIII II II II I1111111111111111111111IIII 111111 II IIIA 11111 II II I III 111 11111111111111111111 II111 11111111111111111111111111111111111111111111111111111111111111111IIIII II II P L I APPROVED V APPROVED WITH CONDITION(S)'- DISAPPROVED 1 1 SEE P+TTA ENT WITH CONDITIONS) A Y` n D - DATE trJJ I N 1 PLAN REVIEWERS NAME t`��,C1I# � +---111111111111111111111111'I IIIIIIII II II II II IIIIIIIIIIIIIIIIIIIIIIIIIIII IIIII 111111 I11111111111111111111111111III IIII IIII Iiiitli 111 1 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: _ "I CERTIFY 1 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 CERTIFIES THE I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA." I I I I I I 1 TITLE • DATE APPLICANT'S SIGNATURE: Go.v 5 Tief_/N C-'--------- ----------------------------------------------.--------- +------------------- - 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 A07"0 4WSIA- /NC Address 106 CWU_wdoD AWS SJireC Phone #-T" 72�-4/za 0C6q-MS/DE, CA 921054 Signature (J-0 LF- EH230038 �� i .e�;�y.. (revised 1/31/02) Z) v; k4% mac. ��'' "� � e<fTkfes i`�/t5/aZ_