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t r <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3FiD 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 /> ____TANK RETROFIT _/,PIPING REPAIR/RETROFIT ____UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> ' EPA SITE # PROJECT CONTACT & TELEPHONE # <br /> i <br /> ----------------------------------------------------------------------------------------------------------------------------- <br /> F 1 FACILITY NAME Fie P,,jv-'S (Do(,_____S�� ___ ___ _ _____ _ <br /> _ PHONE # _���//JJ��\ <br /> C -�1ADDRESS 207 Z -N �Li yy�;^1! �'v/ G ---- 53.3-_^-------------------------- <br /> i L i CROSS STREET <br /> I ______________________________________________________________________________________________________________________________i <br /> T i OWNER/OPERATOR ; PHONE # <br /> Y <br /> ----------------------------- <br /> ---------------------------------------- <br /> C ; CONTRACTOR NAME BaNK -- Co . i PHONE # <br /> SS� -��� 35"4 <br /> --- -- - <br /> N <br /> ' CONTRACTOR ADDRESS CA LIC # CLASS <br /> T . 03 C Bt�r"aNr 383'5�TC) ' ----- � C-(0ef�g01140Z. <br /> R INSURER ?S1Nkicr-)LQT- -jam_-1MAQe L�MMyk V` WORK.COMP.# i <br /> A ii_______________ _j;\)5_jMAQe 611M­�klL <br /> C OTHER INFORMATION , <br /> T ____________________________________________________________________________________________________________________-_________', <br /> O PHONE # <br /> R --------------------------------------------------------------------------- ---------------------- <br /> PHONE # <br /> ---------------------------------------------------------------------------------------------- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY i DATE UST INSTALLED <br /> 39- ' 6000 9`7 0�-Tt:IE �.T�gD1i�NF <br /> T 39- 2 L000 jz, (' ar-T--t. <br /> A 39- le- <br /> 1 2-ODC:) 7 0(-T"vJ <br /> .gyp <br /> ! N 39- Cpnn�- <br /> K ; 39- 00 1200 ��bSfr l� <br /> 39_ <br /> � iii � 'vi ii MIM!1ii'iiiii� <br /> ii MI!,! i1� ii . <br /> P 1 <br /> L APPROVED APPROVED WITH CONDITION(SA 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 THAT IN THE <br /> 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 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> i <br /> i <br /> ! APPLICANT'S SIGNATURE: W �� TITLE 1 Z 6S)LJY NDATE �/�O <br /> --------------------------------------------------------------------------------------------------------------------------------i <br /> BILLING INFORMATION: <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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Address__—_—Address_ 072-_W. , _ ! ti'rCAPhone # 2`2g-�-34'9 <br /> — --- r� �------ — — ------- <br /> i <br />