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• ENVIRONMENTAL HEALTH DIVISION • <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, TANK LINING, 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 /> X TANK REPAIR/RETROFIT _TANK LINING _ PIPING REPAIR <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE #Keith A . Tallia 209-754-1808 <br /> F FACILITY NAME Bobcat Central PRONE # 466-9631 <br /> A <br /> C ADDRESS 1113 N . Shaw Rd . , Stockton CA 95205 <br /> 1 <br /> L CROSS STREET Fremont <br /> I <br /> T OWNER/OPERATOR Lou Franzia PHONE # 466-9631 <br /> Y <br /> C CONTRACTOR NAME Oil Equipment Service PHONE # 209-754-1808 <br /> 0 <br /> N CONTRACTOR ADDRESS 952 CA LIC # 323417 CLASS <br /> T qqn A-Naz <br /> R INSURER State Comp Insurance Fund WORK.CCMP.# 265057 <br /> A <br /> C OTHER INFORMATION <br /> T <br /> 0 PHONE # <br /> R <br /> PHONE # <br /> TANK ID # TANK 512E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- jjt� racnlinp <br /> T 39- Ili pspl <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME �X— 7 DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT [N THE P "ANC THE WORK FOR WH IS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CA FORMAQ�z." <br /> i <br /> APPLICANT'S SIGNATURE: TITLE Pres . -DE$ DATE 6/ 1494 <br /> eith A . allia <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the <br /> party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br /> the billing by signature and date below. <br /> Ram Keith A . Tallia - Pres . - Oil Equipment Service <br /> Mailing Address P . O . Box 950 , San Andreas , CA 95249 <br /> Day Phone r ( 201 754-1808 <br /> Signatu <br /> _�Kelf th A . n1lf a <br /> H 23-0038 <br /> 1 <br />