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- a OZ OC) SAN JOAQUIN COUNTY OCT 2 3 2003 ENVIRONMENTAL HEALTH DEPARTMENT 304EWEBER AVE,3RDFLOOR NVIiIJNMIEN{ HEALTH STOCKTON,CA 95202 PE R�✓��T/\E R VI C F S 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 REPAIRIRETROFIT ------------------------- { { EPA SITE # -----1_PROJECT_CONTACT &-TELEPHONE # +- pAN_Av_t C N__�_I_ �44 -_ _1 --------__-, F------------------------- - � { F { FACILITY NRME2` A M { PHONE #----------------------------------- { { C { ADDRESS { -------------------------------—----------------{ { L { CROSSSIKEZI { I +--------------- Q1 N�I►�F 2--L A N F--------------------------------------------------------------------- ----- ---------- { T { OWNER/OPERATOR i PHONE # { Y _ _+{-- P 41f _ AJ _PAT_CoT _�- -------- --------------------- ---------------- { C { CONTRACTOR NAME , PHONE # 5.�--k--AtVG --CJ --- ~ACTT-�'`c3 +�luC------------------ ----------- --------`0�� 1Q�_oo ---------I IO +--------------------^- { N { CONTRACTOR ADDRESS4 ' �A `' { CA LIC # { CLASS_ I) - t 'l��------- R -1 { T ---------------------- -----~�N.�{.�_A_ISE,S .r,► .._ J�cl�ca-------------1—a �--------- �./-.AZA-+r2,[L { WORK.COMP.# { R { INSURER S�az __ - Nr------------------------------------------------- +------------ 7000�4�_l__o { C { OTHER INFORMATION { { --------------------------------------+----------------------------------------� O { { PHONE # { { ----------------------------------------+----------------------------------------� { { - { PHONE # { +---1111 ii ii 11i 1i i ----------------------------------------------------------—--------------------------------i � �ii{ii{{{{ii{{{{{{{iii{iii{{{{- { { TANK ID # { TANK SIZE { CHEMICALS STORED CURRENTLY/PREVIOUSLY { DATE UST INSTALLED { ( 39- { { T { 39- { { A { 39- { { { { N { 39- { { { { { K { 39- { { 39- i { i { 39- { i { i {i{{{{{i{iii{!ii .� i {� � i� i {{ i { { { {{i{{iii { {ilii i P { { L { A PROVFyp APPROVED WITH CONDITIO S) DISAPPROVED { A ", I (SEE) T CHMENT WITH CONDITIONS) { N , PLAN REVIEWERS NAME f DATE {{{{� ii {{{{ 1 ii{{i{{{{{{i{{1{{ {{{ {iii{iii {{{{{{{{ { { { {iiii i{{wi { i { iii{{ {{i{iiii { 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 LICETtSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I 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 { BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE { FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO { WORKER'S COMPENSATION LAWS OF CALIFORNIA." { i i i { APPLICANT'S SIGNATURE: TITLE A DATE 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 A ti. A ur r F IN Address L jt+(eo (,�. Cd 9`00P Phone # 13 Signature E H230038 }tyz l/�� yC- (revised 1/31/02) ( a 1 .