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0 C] SAN JOAQUIN COUNTY ` 0 ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 30 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 _KUNDER DISPENSER CONTAINMENT REPAIR/RETROFIT 5,m 0 cI YZ�tlij +- ----------------------------------------------------------------------------------------------------+ I I EPA SITE # 1 PROJECT CONTACT & TELEPHONE # I F I FACILITY NAME I PHONE # A ----------------- / t7-- --� '� 1-�P�V�----------------------------------- F ------------------------- -- I I 1 ADDRESS 7-3-0-0 3-n-F"--� ---"-�-__L!_Q 40 --it-------------------------------------------------------------- I ---------------------------------------------------------- I I L L CROSS STREET V 1 �-------------------------------------------------------------------------- - -- -I 1 T 1 OWNER/OPERATOR I PHONE # I Y I -----d-t1}5----------------------------_C�l!q 1 C 1 CONTRACTOR NAME ONE I I 0+------------------- -e � ---T cA_no_Locii_C,5----------I--7-7--!_L3§ H------# _L3§ 609 `i -(----I T N I CONTRACTOR ADDRESS i} I CA LIC # 75 i I -LASS 1,67 I Ij ``- ------------------------------------------------------ R ------- s's------ ss�------------------�--�---------- -1- Ci D -F-"` �" 1 R 1 INSURER s'7 / 7 I WORK.COb1P.#-pj('i cl/ L�3 Vv --------------------------------------+--------- -- - 1 47 C I OTHER INFORMATION I I 1 T+------------------------------------------------------------------------------------+----------------------------------------I 1 0 1 1 PHONE # I R+____________________________________________________________________________________+________________________________________1 I I I PHONE # I + IIIIIIIIIIIIIIIIIIIIII1111111111---------------------------------------------------------------------------------------------i I I TANK ID # I TANK SIZE 1 CHEMICALS STORED CURRENPLY/PREVIOUSLY DATE UST INSTALLED I 139- 81 I T 1 39- G7 e�LAwC I I I I I A 1 39- I N 1 39- G I I I I 1 K 1 39- I I 39- 5 v pt jL, I I 139- 1 I I I +___i{ILII{11111111111i{Illllililllllllllllllllllllllll IIIIiIlil11111'.lt I�I JIIIIIlil11{IlIli1111111111111111111111111111111111111 IPI I L I _ PROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED I { A { S A ACHMENT TH CONDITIONS) l I N 1 PLAN REVIEWERS NAME DATE t +---iil{111111iiiillllli{iii III it{111111ilillll lilli{1111111 illlllllil1111111{iil{IIII{1i{11III1i11 11111 {iIIIIIlilliilll At, /n I 1 I 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 I I 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 I I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I 1 WORKER'S COMPENSATION LAWS OF CALIFORNIA." I I I I IbA I I APPLICANT'S SIGNATURE: TITLE fic I4 DATE I I I -----------------------------------------------------------------------------+ BILLING INFORMATION: �'-�I'�'~ J` - 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 # 1