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0 • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 34D 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 tf I PROJECT'CONTACT & TELEPHONE M 1 G N A 1° !. LVA t."r0 d 91(6 - 3 43 - j t.7 �L I+-----------------------------------------------------------------------------------------------------------------------------I F 1 FACILITY NAME jZ o g r - A ae- m A e ii_F_-"' �' a s I PHONE # v_______________________________________________________i C 1 ADDRESS /-5- C. a hovr L l tAE 20 - 1 I+------------------------------------------------------------------ ---------- --------I L 1 CROSS STREET L 1 itLr L ------ -------------' --'"-i I__________________ Q _____ _ 1 ___�______________i___________________________________ 1 T 1 OWNER/OPERATOR PHONE N 1 Y 1 K F Ar rL E. w1 Asst. tL F✓f-S 1 S f o- 3 Z' ,$ )-00 1 ---+------------------------------------------------------------------------------------+----------------------------------------1 1 C i CONTRACTOR NAME', / A �. -�O % % �,• rc.IL wL(� (I PHONE M C114 31.3- 1 I $- L W------------------------------------------------------------------- i 1 N 1 CONTRACTOR ADDRESS . p O Z i W- s Acro C A I CA LIC # 61 } L 3 If I CLASS A, % I4 A� i P -o--- --- �-------------------------------------------------------------- -- ---�- 1 WORK. R 1 INSURER t A -r E PV !LD ---------- - ------ - ----- -- ----- I -�-4 '+ 13 �{ 9 L } - 0 Z- IA I---------------- �----------------- 1 C ; OTHER INFORMATION I ' 0 1 I PHONE M R+----------------------------------------•-------•-------------------------'•--------+---------------------••-----------------1 1 1 PHONE q +''lllilllliilillllllllllllllllllll---------•______________________________________________________ I i TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED 1 139- OI 1 1'z' 00 1 C. AS0LIUE 8� I urLl� 1 T 39_ 'i.- 1 ! L 00 0 l A; 39- 3 1 / L,000 N i 39- K 39- 9-KI39- 1 1 1 I 39- I i 39- L PROVED AP1 1 +'-'11111111111111111111111111111111111111111111111111 Illlllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllliill P I i PROVED WITH CONDITION I31 DISAPPROVED I l A (SEE A WITH 1 N i PLAN REVIEWERS NAME DATE +___Illi{li{{illlillllllll 1111 I II I II 111111111111111111111111 111111111 III1111111111111 11111 11111 � IIIlllllil i i 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 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 1 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 COMPENSATION LAWS OF CALIFORNIA." I i i 1 � I 1 APPLICANT'S SIGNATURE: TITLE Co"�R A�Ton.- DATE 6 I y --I - (- - Ec.- ----- -------------------------------------------------------- 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. Names~�—�---AddressP_Q. So-(. /o zti------------Phone #_qr6_3 :3 _11 s z Jwl c vt or c. WA c rop W - S A'G" , CX 9 r6 t (