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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 +---------------------------------------------------------------------------------------------------------------------------------+ I EPA SITE_#_________________________________�—PROJECT CONTACT & TELEPHONE # 1 I +-------- -----------------------------4�-- e,�j n--- f� "y I F I FACILITY NAME / L i�a I PHONE # IA +---------------- 13�1?C��--- ---t-� 5-----------------------------------------------------------------------------I C I ADDRESS I [g, a II +--------------------- ---- W �' z------------------------------------------------------------------ LI CROSS STREET I S"�'-----ome- - --------------------------------------------------------------------- T T I OWNER/OPERATOR I PHONE # I ' Y ' --------------------------------------------------------------------------------i C CONTRACTOR NAME — PHONE # ------------ — ------------------------------------ ----- _ T N I CONTRACTOR ADDRESS I CA LIC # I CLASS T +_____________________________________________________________________________________________________________________________1 R I INSURER I WORK.COMP.# I IA I------------------------------------------------------------------------------------+-------------------—-------------------I C I OTHER INFORMATION II IT +-----------------------------------------------------------------------------------+----------------------------------------I I D I 1 PHONE # I IR +------------------------------------------------------------------------------------+---------—-----------------------I I PHONE # I + IIIIIIIIIIIIIIIIIIIIIII111111111----------------------------------------------------------------------- ---------I I I TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I I 139- 1 I ( I I I TTI 39— I to 1i I (J�►�It ®-�— I I I A 1 39- _1 I I I N 1 39—:A___I 10 k regi I I K 1 39- 1 9-1 39- I I I I 1 39- I I I +___1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 IPI I L I APPROVED APPROVED WITH CONDITION(S) DISAPPROVED I A I (SEE ATTACHMENT WITH CONDITIONS) I N I PLAN REVIEWERS NAME DATE I +___IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 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 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 I FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORKER'S COMPENSATION LAWS OF CALIFORNIA.'- APPLICANT'S ALIFORNIA."APPLICANT'S SIGNATURE: TITLE DATE I I 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 acknowledge this responsibility for the billing by signature and date below. Name_ _ 1 __Address_ e g _ _ I _Phone#_> h) 1