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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE.3RI 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 /> XX TANK RETROFIT PIPING REPAIRIRETROFI? UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> •_____________________________________ __________.________________ ___________-_______ _ I <br /> IEPASITE " Z��l4Wp5742'6 1PRGJECTCONTAcr ` TEI4I"0" R Michael Sills (562) 597-3977 <br /> 1 ------------------- -------------------------- <br /> 1 P I FACILITY NAME Yellow TransmTv3rtatlon Inc. 1 PI(G1E # 1 <br /> A •_____________________________________C._________ <br /> ___________________________________________________________________f <br /> I c 1 Rimmisss 1535 E. Pescadero Ave. , Tracy, California 1 <br /> ' I •---------------------------------------------------------------------------------------------------------------------1 <br /> 1 L I CEl S'RER"'Paradise Road 1 <br /> 11 --------------------------------------- ------ <br /> I T N OWNEIVOPERATOR 1 PNGNE k ____ <br /> Y i YTI/Steve Shinners ' (913) 344-3615_________________ <br /> ---------------------------------------------------------------- --___-----------•- ----- --------------- <br /> 1 C I GDNI+xsoe RAKE Professional--Service- --Industries_P- _In5z--_-__-_ <br /> O •--------------- - (S62)__597-337.7_____________ <br /> - - - - -------- - - --- <br /> I N I CONTMCIOR ADDRESS I CA LIC P 1 CLASS I <br /> -------------------------------------- --- .�_LQng__Bch.__Ca.___---7157.03--------- _A,__C5.7___--_____I <br /> I R I INSURER "ORE"` -"wc658042-12 ' <br /> I A f---------'= rsY3__'tSeo_LQgaa_8q.+_Philadelphia.-3�_131D3__._-----___-------------------------------------- <br /> 1 C I OTHER INFORMATION Gen. Lia. GIA 6580471-12- 1 <br /> _____-____ <br /> _ <br /> 0 1 1 PHOEE N I <br /> ---------------------Ajjtp.jj?,l _$AP-65&0472-12------------------------•---------------------------------------I <br /> (215) 2-46-1367- - - 1 RHDRE N t <br /> •---. a�..,�.: ,,,;1„ii.i,,,,,,,,,� ---- -- - -- ------------------------------------- <br /> TANK ID R TANK SIZE 1 gQTIZCALS STORED C(REA9TTLY/PREVIGI3SLY DATE UST INSTAI...en <br /> 139- 1 i 10.000 1 Detergent/Soap 89/90 <br /> 39- 63�0�000 Waste Oil 89 90 <br /> I A 1 39- J._ —b VUU Anti Freeze j <br /> N 39- Gear Oil ! <br /> K ; 39- 5__ _ 0,000 Motor Oi <br /> i- <br /> 39- 6 4,000 Spill f.Qatainment _ R9/90 <br /> 39- 7 1,000 Wade 031 (OWS) 89/90 <br /> i,.,. ,i „ <br /> P <br /> L APPRUVED APPROVED WITH (IITIONN) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PIAN EEvni R3 NAlN: DATE <br /> APPLI4IARI MUS: PERFORM ALL WORE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE :AHS. AND RI AND REIRZLATIONS OF <br /> SAN JOAQUIN COUNTY, ENVIRONMENTAL RZALTH DEPARIKEIM1. 'OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TRE FOLLOWING: 'I CERTIFY TEAT IN THE <br /> PERFORMANCE OF :?@ WORM FOR WHICH ^'.IS FERMIT :S ISS ED. . I SHALL .NGT MPLOY ANY PERSON IN SJCN ARA? ER AS TO <br /> FE-0ME M WORKER'S COMPENSATION U S OF CALIFORNIA." IONTPACRJR'S HIRING OR S_-�NTRAIT:HG SIGNATURE CFRT_F:FS :HE <br /> FCLLOIiING: "I CERTIFY THAT IN THE PERFORMAl OF THE NARK FGR WHICH THIS PERMIT IS ISSUED. I SHALL 6 OY PERSONS SUEJECI TO NORKERN <br /> CG4@ENSATION LAWS OF CALIFORNIA.• <br /> APPLICANT'S 0IGmIll i TII- Sr. Project Mqr :A a' f'-O,I <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 Professional service Address 3960 Gilman Street, Long Beach Phone # 562 597-3977 <br /> Industries, Inc. Ca. 90815 <br /> 1 <br />