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E SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3RD 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 REPAIRIRETROFIT ____UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ---------------------------------------------------------------------------------------------------------------------`11,14•-------- EPA SITE M PROJECT CbNTACT s TELEPHONE M M C N A 9 L- WA Li Q rA __3 �) -_ I s - Z! i•-----------------------------------------------------------------------------' _ F ; FACILITY NAME Q U `V/ c.Top * I q r I -PHONE k S-10_ (CS,)- FS -00 i A•________________________------•-•-;----____---____�____l ______-_-__----_-_---____----_,______-_-_-_--________---_______ Z C I ADDRESS 0 C, W L 0 G IG i- o w D sr 4 0 D l CA S' z o L; CROSS STREET I -- ttv,sCLt ST - •--------------------- -- ---------------------------------- T ; OWNER/OPERATOR i PHONE M Y Q �! l t[ S':0 !� A-r1.1G r�r-C I CONTRACTOR NAME A L -T— ,0#4E I.0 C L.E.2 u'C• " PHONE a 9! 6 i 3 I I S Z o • -- - ------------------------------------------ P. P f CA LIC » 1---------------------ZNCONTRACTOR ADDRESS fCLASS_ _ ,_k'- R INSURER S T A•T- E r v I WORK. COMP. n '" 13 _ q9 z} O Z C OTHER INFORMATION I ' T_______________________________________________________________________________ 0 , I PHONE # R------------------------------------------------- _---------------- ____________________________________________________________ii I PHONE # •---I I�IIIIIIIIIII II 11 1 - 1 ---------------------------------------- ---___-------------------------------------____----- �IIIII�IIIIIIIIIIIIIIIII111111 TANK IDR I TANK SIZE I CHEMICALS STORED CURRENTLY/ PREVIOUSLY DATE UST INSTALLED I 39- 0t I 140,0400 CA,5OLi+IF T ; 39- 4D Z• I ' A 39- N 39- I ' K 39- 39- 39- P 9-39-39 P L APPROVED V APPROVED WITH CONDITION(S-)*,K- DISAPPROVED A (SEE ATTACHMENT ITH CONDIT 57� \\I�� N PLAN REVIEWERS NAME iK� +�� DATE • --I Iii IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIII III ILII 1 III 1 II IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIi ii APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,TE LAWS, AND RULES AND REGULATIONS OF 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 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." 1 APPLICANT'S SIGNATURE: TITLE PnEs� DATE �l t IP 3 • - 1 C 41 A-94- - --SVA r To�------------------------------------------------------ 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. P.O. g0X Iota q16 Name__ _lN A t. o*AAddress—__lN- S � rt & +1 �_r-O______Phone #_3 1- �i+r'- 1