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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />304 E WEBER AVE, 3RD 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 REPAIRIRETROFIT _UNDER DISPENS CONTAINMENT REPAIR/RETROFIT <br />+-------------------------------------- -- — -------- — _ _ <br />1 1 EPA SITE # I PROJECT CONTACT 6. TELEPHONE # 4 T �' <br />1 +'--------------- �— — --- — — — — d_. <br />I F I FACILITY NAME ' -- --! PHONE # 4 —1 <br />eA +---------------- — -- — ---- --�— ----- <br />C <br />-------- ---- ---�� <br />e <br />C I ADDRESS <br />{ I ---------- — ---- — — — — — -- -- 1 <br />1 <br />----------- <br />-- - -- - <br />I L I CROSS STREET --- -- -------{ <br />1 I +------------------------------- --------------- <br />T T I OWNER/OPERATOR q I PHONE # <br />YI I , <br />i---+--------------- - - - ----- -- --- ---- --------------------- 1_ <br />C I CONTRACTOR NAME 1 -- <br />--------- ® PHONE # e <br />N I CONTRACTOR ADDR S e e <br />—CA LIC # <br />1 T *---------- � � 1 i. � { CLASS � (I� � e <br />--- —----------- -- — �-- ---- — -------- t <br />R <br />I INSURER I WORK.COMP.# <br />I C I OTHER INFORMATION —I <br />----------------------------------------------- <br />0 1 <br />' R +--------------- PHONE If <br />PHONE # <br />1 <br />i --Il{illi{111ll111{111111111-------------------------------- --- <br />TANK ID41 <br />— 1 <br />TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED <br />1 39— <br />T 139— 1 I 1 <br />A 1 39— I { 1 <br />I N 139— I I I e <br />1 <br />1 K 1 39— 1 I 1 <br />1 ' { { <br />{ { 39— I I { e <br />�—p—I11111Ill; Ill I 11111111111 -pill Ill 111111111till IIliIIIllIliI MI! 1IIIIIIIIIIlI,,li m 111111111{11111111111111111111 I!Ii11111111111 <br />{ L i APPROVED APPROVED WITH CONDITION(S) DISAPPROVED 1 <br />{ A I (SEE ATTACHMENT WITH CONDITIONS) <br />N_1 PLAN REVIEWERS NAME 1 11 i „ e eee ee a epee , e i DATE,eeeeeeeeeeeii <br />+-- I{Ielellelle11111II11 1;1;11;1111111 1111; 111111111111111111111111111111111111111111 �1h11111111{1111111 elllellleeee;eeeee;e;e <br />I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF � <br />1 <br />y SAN JOAQUIN COUNTY, .ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: ^I CERTIFY I <br />I 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 I <br />I BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT WNISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I <br />WORKER'S COMPENSATION LAWS 9ij CALIFORNIA. - <br />APPLICANT'S SIGNATURE: <br />ALIFORNIA."APPLICANT'SSIGNATURE: ' TI E )�thkpAUTE l <br />l <br />T- F ^a. lDtlb/v2, <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 <br />owner, the party must acknowledge this responsibility for billing by signature and date below. <br />Nam44A-e46LAddress , Lk - <br />Phone / <br />A a„r f IAA , <br />Signature lI <br />EH230038 <br />(revised 1/31/02) <br />1 <br />