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11/30/2004 11:53 209468343FIFTH FLOOR PAGE 04 • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 300 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 ZF31PING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIRIRETROFIT +-------------------- -------------------------.-.------------..----------------------------------------- ( ( EPA SITE # Q -_Q �_ CO - ----- 1 PROJECT CONTACT & TELEPHONE #a � �� ------ ----------- EPA +------------- -!- - - -------------- ---is---- K -------- 1 i -------------------------- F 1 PACILITY 3TAM$ \1 !) r -------- r P j� �n}�nn /� 1 i 1 A *-------------�`-JZL=i.Q------`r• -� --- ---- _ ` PHONE i! av l _ `l1 _ �J��---1 C ADDRESS ( L I CROSS SM= N i�-------------------------------------- ------------------------------- L I= +----------------- J� --- - C© -------------------------- ( T I OWNELZ/OPERATOR ------------------------------------------------------ PHONE # IYr I---*----------------- ---- ------------------------------------------------+-----� = U.. =- -------- -9---- 1 C I CONTRACTOR FAME I +------------------ ��--- -� Cir L4 -------------------------------- 0 ------------- h_ I N I CONTRACTOR ADDRESS # 1 CA LIC # ^ 1 CLASS 1%4Zi A) C- ZI, c I V• l7 IT +..__---------._.._--- __ 5 ----------------- s,� _`S_ ----- ----._---------__. y� y� ` r h r' a OOODo _ A I-�`----- SURMZ ccJ ' �. �L_M.d?M..--------------- I WORK. COMP.#D..� --- ( C 1 OTR.$ INFORKATION G-'0nr ITt--------------------�..IG�.-.0----_.._...._---- I O I 1 PRONS # 1 IR�----'_-------------------------------------------------------------------------*----------------.-----------------------i I i -1 _PHONE # +---IIIrIIII{I IIII111111111111111111-------------- -______---_----------------------_____ ______ i-.----__-_----------_ 1 ( TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 1 r I T IA I� r >x l ( IP IL N- 39- 39- 39- 39- 39- 39- 3 9- Irll 1111111111111111111 r _ APPROVED APPROVED WITH CONDITION IS) DYSAYAROVED / T ($Eli ATTACEMENT WITH CONDITIONS) DATE ? OS PLAN REVISWMS XAME J sG�GSv� IIIIII IIHIIIIIIIIIIITI I IIIIIII III III ITIMIMIMIMITI 111111111111111111IIIIIIIIIIIII1IIIIIII APPLICANT MUST PERFM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REC=T=ONS OF SAN JWUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OHNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOI,LOW=NO_ -I CERTIFY THAT IN THE -PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT MQWY ANY PERSON IN SUCH A MANNER AS TO RECOM3 SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIF'OKNIA•" CONTA=OR'9 RZAINC OR SUBCONTRACTING SIGNATURE CERTIFIES THE rOLLOWINc: -I CERTIFY THAT IN THE PERpORM WCE OP THE WORK FOR WHICH THIS PERMIT I5 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OP CALIFORNIA.' APPLICANT'S SIGNATU'R$c 0-�'V ' ` A' TITLE $ �u ��=,V��\S��D.116 )2`7-011 +--------------------------•----------------------------------------------------------------------------------------- - -- .- -----* BILLING INFORMATION: D' -i C 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 WG,,.-� V2 r�j i --Cr . Addresses ,-A-..- Au c,. S"SCC -t,-f-. Phone # (q 16) 6`c G Signature �L'j4, EH230038 (revised 1/31102) 1