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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3`m 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/RET <br />�O <br />+--------------------------------------------------------------------------------------------------- --- <br />+ <br />--- -- <br />--- -( <br />t t EPA SITS # PROJECT N & -/ - �G-+ - m���,� <br />�---------------------- <br />I <br />-----._ _--- <br />t F tFACILITYNAME� PHONE # 10 <br />J______ <br />ADDRESSCI*'----------1-�----------------------------------------I(y1---------------------------------------------- <br />L tt <br />t CROSS STREET { <br />---------------------------------------------------------------------------------------------------t <br />T i OWNER/OPERATOR PHONE # <br />Y )R i { <br />,e 1 C ,� t <br />t---+-----'-----' - -------------------------+--------'------------------'---------- <br />PHONE # <br />I O +--------------- { <br />------------------,-% <br />N CONTRACTOR ADDRESS /��f ///� /n(/� T CA LIC # /�//,/-, J �j/(�/ %%v <br />4 <br />T+-------------------�J_SA�_J� ox---� - `� t - Ste_``'_I!_�__- CLASt,--e <br />-- --- I'1 <br />R t INSURER t WORK.CCMP.# t <br />tA{____________________________________________________________________________________+________________________________________{ <br />t C t OTHER INFORMATION t I <br />----------------------- - -------------------- <br />t O t t PHONE # t <br />i <br />i i t PHONE # { <br />+---tttitttt{ittttttttt{{{tttt{tttt{----------------------------------------------------------------------------------------------{ <br />t TANK ID # TANK SIZE C//jCAISp/gip CURREITL PRSVI S Y DATE UST INSTALLED <br />39- 7-1 { '"-OC% 0 t /5�4' GSC//l��C+ u�1�%� { <br />t T t 39- t -©© d <br />t A t 39' t i t <br />i <br />N 1 39- <br />t K t 39- <br />i <br />t t 39- t t t t <br />t 39' t t t t <br />+---Iltt llt tl lttll l{Itttttll It tlttt ltt It tttttltttltt t1 til tt{tttttltttt lttll ltl{t tl ttttt tl{ttl{ttl{t ttttlt{t It tt ttlll ltl tl{tlll tt l{ <br />t P i t <br />t L t _ APPROVED APPROVED WITH CONDITIONS) DISAPPROVED t <br />{ At V f�1�1 (.��A TS�'ACHMENT WITH CONDITIONS) <br />t N { PIAN REVIEWERS NAME G DATE { <br />+--'ti{ttttitttttiittittttttttitttttttttttttttttttttit{t{{t{ti{tttttttitittiit{tit{titttttttttt{ittttttttttttttttttttttttti{tittitt <br />t <br />t APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATS LAWS, AND RULES AND REGULATIONS OF t <br />' SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY t t THAT IN THE <br />i <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO t <br />t BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CfiR2TIFIES THE t <br />t FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL E7PIAY PERSONS SUBJECT TO t { WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." t <br />t <br />t <br />t � t <br />t APPLICANT'S SIGNATURE: TITLE (J J tk� DATE----------------------------------------------------------------------------------------------------------------------------------- <br />t <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/1Z412rG1"ddressC�/ / /.3/6 /0-�C Phone #�r�� <br />