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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 FRO�THPPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: TANK RETROFIT _ REPAIR/RETROFIT ____UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +---------------------------------------------------------------------------------------------------------------------------------+ EPA SITE # i PROJECT CONTACT & TELEPHONE # +------------------------------------ --------------------------- F 1 FACILITY NAME /�� `I/� c- ��% PHONE # l�j �t✓---------------------------------------------------------------------- --- CADDRESS � -------� 5----------------------------------------------------------------------I L i CROSS STREET ------------------------------� T OWNER/OPERATOR PHONE # Y i----------------------------------------------------"-----------'+------------------------------------__� C i CONTRACTOR NAME ______� PHONE # 7C 1 ' - --------------------------------------- ----- - ----111-Q-- -� -- N 1 CONTRACTOR ADDRESS__ _ ------ W__r__' — V _ 1 6nj-c-CA LIC_#___________________ --CLASS R 1 INSURER i WORK.COMP.# A-------------------------------------------------------------' --------- +---------------------------- C OTHER INFORMATION 0 1 1 PHONE # PHONE # ______________________________________________________________________________________________i TANK ID # TANK SIZE CHEMICALS STORM� C'UR/R]ENTLY/PREVIOUSLY DATE UST INSTALLED 39- i�_ , S L A 39- N 39- - K 39- 39- 39- P 9 -39'39'P L APPROVED APPROVED WITH CONDI ON(S) DISAPPROVED i A ( A WITH CO -JONS) (� N PLAN REVIEWERS NAME DATE YV-Y 1 i i i i i i i i Nwiiiiiiiiiiiiiiiiiiiiii iiiiiiii H i i i i i 10, 1111111111111111111 i 1 ii i 11111 !it,, iii 111111 !!A... ....... 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 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 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE DATE +----------------------------------------------------------------------------------------------------------------- + BILLING INFORMATION: THAT IN THE WORKER'S 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 ress Phone # sem. l 4