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SAN JOAQUIN COUNTY ENNOONMENTAL HEALTH DETMENT 304 E WEBER AVE, 3R0 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: �� XP//hase S Q�TANETROFIT _PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT -------------------------------------------------------+ EPA SITE -#-- I_PROJECT CONTACT & TELEPHONE # �ei9�%lzntn0 �KN4.�-m-si3'O170oI +--------- - --------------------------------------------------------------------------i I F I FACILITY NAME It 2-0 - $1 17 6bevrmi FirodUr-ts Co- 1 PHONE # -------/-�--------'------------------------------- 5 Gi C I ADDRESS 755 + Tr215tYa" , 'Tracy , -1537& II+--------------------------------------�=---------------- -----------------------------------------------------------------I I L I CROSS STREET II+----------------------------------------------------------------------------------------------- -----------------------------I T T I OWNER/®PBM"" I PHONE # I Y I Chevron froduc-ts Co. (Attn: David Lyons) I (925�642-4387 I I C I CONTRACTOR NAME 52%/idge. Construction , In C. - I PHONE # (530) 622- 1982 I IO+-----------------------------------------------------------------------------------------------------------------------------i I N I CONTRACTOR ADDRESS -4401 5Onj2 COU rt, FjWX,Vt11Li CA LIC # 7558`t S I CLASS A , HAR. I IT+-----------------------------------------------------------------------------------------------------------------------------I I R I INSURER 5t t6 Comfvens2ti wl I tns tira n ce Fuhd I WORK. COMP . # 27S-2003 I IA I------------------------------------------------------------------------------------+----------------------------------------I C I OTHER INFORMATION I IT+------------------------------------------------------------------------------------+----------------------------------------I 1 0 1 1 PHONE # I IR+-------------------------------------------------------------------------------=----+----------------------------------------I I I I PHONE # I +---IIIIIIIIIIII11111111111111111111----------------------------------------------------------------------------------------------I I I TANK ID # I TANK SIZE I CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED I I 1 39- 01 000 I M. un1' 1 199 S T 139- d2. I �S,�Oy I_ M.on IA139_ 1 1 I I IN 139_ I 1 I I 1 K 1 3 9_ 1 I I I I 139- I 1 I I I i 39- I I I I �ZAPPROVED IiiliiHIIII 11IIIIIIIII IIII11111111111111111111I111111111111111111i111II PI I L i PROVED WITH CONDITION S) _ DISAPPROVED T A I (SEE I S) I I N I_PLAN REVIEWERS NAME V DATE +___IIIIIIlIl1IHill IIIIlllllllll IIIIIIIIIIIIIll I111111111111111111111111111111III1II111111111111III I II 1111 111111111illlll I I 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY I 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 I 1 FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I COMPENSATION LAWS OF CALIFORNIA." I I / y 1 APPLICANT'S SIGNATURE: � TITLE � 1t �Dr ChNron DATE � 21 0>} R L �� o/ nG, +---------------------------------------------------------------------------------------------------------------------------------+ BILLING INFORMATION: THAT IN.THE 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. Name Nt- t�i�n &'oupIno_Address_ 1340 Arnold Df. 0Ito t1a�— r+i rtiet Phone # US- 313-1700 -- -- 84553 ext 10:7 Si natur 1'� nt 61 EH230038 1 (revised 1/31/02)