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* f <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL E L EPA T ENT <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 />+------------ _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />--------- --------------------------------------------------------------------------- <br />{ EPA SITE # !PROJECT CONTACT & TELEPHONE # L® p,I <br />Fe <br />.Es H mA K ! Q' (p) $5® <br />v -f j® ® <br />() I'1+'-------------------------------- <br />F 1 FACILITY NAME l ®Sos0 PHONE # (20q9)(u2— 1(0(A +-----------------------------------"------------------------------- <br />t • ------------------ <br />-------------- - --------C 1 ADDRESSp ycEh®N_ 5 ®CCT,09 > e AI ------------------------ <br />:{ ------------ <br />L 1 CROSS STREET <br />I _�----------- <br />I <br />---- <br />I +------------------- ----------------------------- <br />{ <br />1 _ -------i -------- <br />- - - --T OWNER/OPERATOR PHONE # ----------- <br />Y <br />----- <br />1 Y -8P <br />-iW------------------------------------------------------------------ <br />C <br />J 3535- <br />----------- ----------- <br />--------C 1 <br />1 CONTRACTOR NAME ^ G 9 1.g T <br />----- � -- t"----- V. `J y s I PHONE # C _! (-------------- <br />N <br />O_ SS_ �_( - V 1 <br />{ N { CONTRACTOR ADDRESS- 3Z$ Lu Y U N G V k . I S�� ® ` -- -CLASS 12101 6 A RSg !� PC 1' <br />IT +------------p------- c---------------------------------------CA-LIC # <br />{ R { INSURER 151 A K KE -� SC H A GN ` T 2 ----------I---------------- ----- -'{ <br />I A I ------------------- WORK.COM--- ®g2P5do®t$SO Z. l <br />{ C { OTHER INFORMATION 1 1 <br />I T +-------------------------------------------------------------- <br />----------------------+- <br />M__ ed R O P 71A V f _ D (V Z I PHONE # <br />l R +------------------------- - ---------- --- --� 0 5- _ <br />I... <br />+- I _ <br />PHONE # <br />------------- : <br />{ TANK ID # ---------'-----'------'---------------_I -----------------{ <br />I 1 39- / 1 TANK SIZE I CHEMICALS STORED CURRENTLY/ PREVIOUSLY DATE UST INSTALLED <br />I IrK <br />T 139 1 <br />I <br />I A 1 39- 3 I I c I 1 I 1 <br />"t <br />I N 1 39_ i I <br />K l 39- <br />1 39; 1 I <br />I 1I <br />I 139, DI : <br />+--Illill I{I:I 111111111{1' :: l t J_TSE <br />"ATW <br />11111 1111111 1111:111:PL { APPROVEDAPPROVED WITH CONDITION(S) DISAPPROVED <br />{ A I WITH CONDITIONS _ r7 ��DATE a�2 ' <br />{ N { PLAN REVIEWERS NAME �A �v i <br />+---llll{11111{1111111111111 Illl11111 I lilll IIIIIIIIIII{lI{ill IIII III{I I{I{IIIIIIIIIII III Ilii {l 111111111{ilii <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 />i ' <br />� T'S SIGNATURE: ,yy/ �9 ' <br />APPLICAN <br />� ,Q -��✓ TITLE /01� DATE / ' <br />I <br />+------------------------------------------------ <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 .61° 1)E5 r CORST P/200 -Address `/ �P+t�re �or66 ,/ r Phone # C2os) tay9- 33,35 <br />Signature <br />EH230038 <br />(revised 1/31/02) <br />01 <br />