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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 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 ------------------------------------------- --- -�-1--------------+ EPA SITE # - I PROJECT CONTACT & TELEPHONE # 14EKQM rL�Vfll� S -0•'1Z'3�44__ --------------------------------------------- I F I FACILITY NAME 15EAGOtz Ur_ I PHONE #(15 16 914Z^ 3 004 A +----------------------------/-- T�L��-'�d2�----------------------------------- ----------- ------------- C I ADDRESS IS Io r= S�--------------- Z,b I +-------------------------------------------- ---- c---------------- -- ---- ----- I - I L I CROSS STREET KAT"L E F,&3 p V , ----------------------------------------------------------------------- I T I OWNER/OPERATOR i PHONE # I I Y I L)c-Z P.-/s V-4 p►Z I N G . I (018 64Z- ----------------- 3(v4 4 I --------`-4G ------- ----------- ----------------- -- - ------------------------------------------------------- C ------- --- ----------------------------I I C I CONTRACTOR NAME J N �./ C�N rJT�'G� O/J 1 I PHONE # 1 0 +-------------------- --------------------- -------------p ------------------i I N I CONTRACTOR ADDRESS C� Z•�j() E C,A,,Lk) � � C IS ,i CA LIC # (p z I R> �j I CLASS A B "6Z �S I G I T +-----------------------------------------------------1---------a- ---------------------------------------- L--L--------------- I R I INSURER rjTA:T-r �=UMC> 1 WORK.COMP_# 4(o_96'j(,-�` I +---- ---------i I C I OTHER INFORMATION MPf L•�0(;, �Dp fL�SS : Ar`J E#--( 11.t r-mt Az(a 1 F ----------------------------------------------------------------- 1 0 I ZD-7 W•'!N-LL1f-d ric>/S 4'\'M. 3 V re-e")�^' C-�-. ' -�Z i PHONE # 61O,04 C.-56n41 I I PHONE_# +--- 111111 11 111111 1111111 11 1 ------------------------------------------------------------ -----------------------------------`----------------------'----------------'----------------i 111111111It IIIII II IIIIIII{11111 1 I TANK ID # I TANK SIZE 1 CHEMICAL STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I I 1 39- I I I z d00 i 87 Sc C.(•n1"�. T I 39' i 10 Fbb� i q K A I 39- 3 I 10 00 i q I N N I 39- I I K I 39- 39- 39- P 9_39-39P I L I APPROVED APPROVED WITH NDITION(S) DISAPPROVED I A I (SEE ^dT WIT OND S) I DATE N I PLAN REVIEWERS NAME �� L ---II IIIIII III IIIIII II II IIIIIIIIIIIIIIIIII,II1111111111111111111IIII III IIIIIIIIIIIIIIIIIIIII I { IIIII11111 IIIIIII . .IIIIIIIIIIII IIII I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 1 I 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 W CH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 1 I 1 BECOME SUBJECT TO WORKER'S COMPENSATION S OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE I FOLLOWING: "I CERTIFY THAT IN THE PERFO CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I 1 WORKER'S COMPENSATION LAWS OF CALIFORN I I 1 I I I 1 I / 1 APPLICANT'S SIGNATUR TITLE'P R�`lKOF..2 DATE 3/4✓ 3 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 acknowle a this responsibility for the billing by signature and date below. g3Z3o Name Ot rt./�MR o . itzC , ddress (PISS w .T�41iv->D s- �{ A.,or- rco.ca. Phone # 819 �4Z-3(x144 Signature (revised 1/31/02)