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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3R0 FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM TH APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: TANK RETRO _PIP FIT ING REPAIR/RETROFIT✓,UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +---------------------------------------------------------------------------------------------------------------------------------+ EPA SITE # I PROJECT CONTACT & TELEPHONE # I ----------------- _!,_Cs aoZSSf9 b --------------------------------- fe..- I F I FACILITY NAME �I„ y I / 6r( I JA +------------------ PHONE # - I I C I ADDRESS 10 �••� I I +---------- -------------- 2_7a r?/.k - - -------- - I L I CROSS STREET (L_________I I +__________________________________ T I OWNER/OPERATOR ®� �`! ________I Y I PHONE �T`f'TT�►�P �' ��✓e«..1.r,� lac b lie �If I C I CONTRACTOR NAME ___+_____________________! I PHONE I I O +---------------- cs�t r<L�✓C�!'it crcf Ser✓�c ��y,c . `4s- .3S$ ,a�'``�--- -- --- -----' --�-- - --------amu---------- N I CONTRACTOR ADDRESS,Al2-Cw ' �+�'1-LJ—{�j(pjr,��'� � P� I CA LIC # �(,Q - - I T +------------------- ................... -— _141t, �� CLASS R I INSURER �L�Y! I WORK.COMP.# L A I-----------------'-- cr�Pt�•_ -tc�� _ c c e ---------- ----------------i C I OTHER INFORMATION - _ ---- ---�-i IT +------------------------------------------------------------------------------------*----------------------------------------I I0I I I PHONE # R +_______________________________________________________________ I I I PHONE # I ---IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII---------------------------------------------------------------------------------------------- I I TANKID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE ST INSTALLED I I 139- -0-1 I d I T 1 39-4 Z I I el 4b I A 1 39- I N 1 39- ItnQ I I IK139_ I I I I 139- I 139- I I I ___II11111111111111111111111111111111111111111111111 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII1111111111111111111111111111111111111111 IPI I I L I APPROVED APPROVED WITH CONDITION(S) _DISAPPROVED I I A 1 (PEE ATTACHMENT WITH CONDITIONS) I , N I PLAN REVIEWERS NAMEDATE ___IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Illlillllllll IIIIII111111111111111111111111111111111111111111111111111111111111111111111111 I I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COMM, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN TIM PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I I WORKER'S COMPENSATION LAWS OF CALIFORNIA." I I I I ` I APPLICANTS SI@PITURE: TITLE � DATE cJ1-2/ /03I +-------------------------------------------------- ------------------------------------------------------------------------- BILLING INFORMATION: 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 d date below. C Name ` vet.x. Address 1h✓ki 1-kec� WN Iftas- Phone# S%5-Zft(. 1