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SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 304 E WEBER AVE,3R0 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: t
<br /> _TANK RETROFIT PIPING REPAIRIRETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT�- -� ✓ k5t(S.LI
<br /> +--------------------- --------------- ---------------------- --------------------------------------------------------------+
<br /> 1 EPA SITE # 1 PROJECT CONTACT & TELEPHONE # M Qr W�k_,L+(Lw q
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<br /> 1 F FACILITY NAME �I : � PHONE # J '
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<br /> 1 C ' ADDRESS f0( C . �o �. �---�V,-----C�-----'-S_. lo(o-------------------------------------------I
<br /> 1 I : ADDR------�---------------------------------1, L �-
<br /> 1 L 1 CROSS STREET 1'1W 1
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<br /> ' T OWNER/OPERATOR�L APHONE #
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<br /> I C 1 CONTRACTOR NAME erU w�-s y�.C. 1. PHONE # c.E�l�_ �i �03 ;
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<br /> I N I CONTRACTOR ADDRESS k eD QLKAP ��- �� , CA LIC # y ?�/ k , CLASS a j b
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<br /> 1 - 1 INSURER CltZb�l� I,.c.@LIQ lL S ��L,_ �Q , WORK.COMP.#' '---------------------------- -- ------ -----------------------------------------
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<br /> 1 C 1 OTHER INFORMATION I 1
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<br /> 1 0 1 1 PHONE #
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<br /> 1 PHONE #
<br /> ----------------------------------------------------------------------------------------------
<br /> TANK ID1# TANK SIZE 1 CHEMICALS STORED CURRENTLY/PREVIOUSLY ; DATE UST INSTALLED
<br /> 39-
<br /> T 39-
<br /> A 1 39-
<br /> N 39-
<br /> K 1 39-
<br /> 39- 1
<br /> 39- 1
<br /> 111111„ 11111
<br /> 11111111111,,,,,,,,,,11111111111,,,,,,
<br /> 1 P 1
<br /> 1 L 1 APPROVEDAPPROVEDWITH CONDITION(S) DISAPPROVED !
<br /> 1 p 4(S--_'A'T,T,A,C,H,M,E,N'T'
<br /> WITH CONDITIONS) lf/ 0,10 N PLAN REVIEWERS NAME DATE ll/
<br /> 7777 1
<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 /> APPLICANT'S SIGNATURE: �-LC-.' y" r'�-�'I.I.�-A--�' TITLE "4U-Q(l4Ata> ���"`�VDATE
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<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 the billing by signature and date below.
<br /> Name 1APjgw V, (KVA-44" Address orb QcianilAm,. ��c&CA _Phone#
<br /> Signature IL,&L rZ4,
<br /> EH230038
<br /> (revised 1/31/02)
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