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A JOAQUIN Q <br />ENVIRONMENTAL <br />304 E WEBER AVE, 3"D FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />jen-TANK RETROFIT _PIPING REPAIRIRETROFIT ®UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+----------------p-----`--------ry-----------------------------------------------------------------------------------------------+ <br />EPA SITE # 6.�� a �% � ® ✓ / --__ PROJECT CONTACT &- TELEPHONE -#----- -__l-_ <br />+------- ----- �C <br />F FACILITY NAME <br />PHONE r <br />A+---------------- '- - - --- -'----- - - -- -' -- -- ------------'-'-PH ` - - - -- - - <br />I C ADDRESS <br />i+---------------------- --- '----- - - ------------------------------! <br />L ; CROSS STREET <br />I+---------------- -- ------------------------------- ------------------------ <br />T 1 OWNER/OPERATOR. I PHONE- <br />------ ------------ --- --------- ------ _ +---------- ---- ----------------------- <br />---+----------------------- ----------------- <br />C ; CONTRACTOR NAME - PHONE <br />O +------------------ -- -- - -- - -- - ------ - ----- <br />---------- -- - - --------^---- - ----- <br />N : CONTRACTOR ADDRESS ® -- ® _-CA LIC # <br />T +------------------ - --[ ----- -1---- - - a-16 -I----------7%3-316-0 -----C---S-- <br />R INSURER r WORK.COMP.# I <br />' A '--------`------------- -------- - ---- --------- <br />C OTHER INFORMATION <br />T+-------------------------------------------------------------------- <br />O PHONE # <br />PHONE # <br />---------------------------------------------------------------------------------------------- <br />TANK ID #I ' I'I TANK SIZE I CHEMICALS STORED CURRENTLY PREVIOUSLY ; DATE UST INSTALLED <br />T 39- (000 A3-1 60 1/80-5 ` .e Y.9 Ca® I <br />A 39- ® O <br />N 39-OU.0,2.314 S` Aii!7�D7 ®®® k✓ CZ E' <br />K 39- <br />39- <br />39- <br />P <br />L ; APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />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 <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLEI DATE <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />Name <br />Signature., . .� <br />d <br />