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SAN JOAQUIN COUNTY ENV..ONMENTAL HEALTH DEF..,RTMENT 304 E WESER AVE,ORO 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: ��/Qha3G= j [TANKKETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ___________________________________________________________________________________________________________________________________ I EPA SITE E---------------------------------I PROJECT coNrncr R Ta.EPNoea #jEat.5a 6alanino (21116) 925•SI3.970D I I *----------- A ------------------- ------------------------------------------------------------ I P I PACILITY WMMQ` - SZCo4 Ci'INron IrcJUG,--S C:o• 1 PHONE O I C I 'VE 5771TraeySled. ' Tracy ' I S3o4 I +---------- __ - - ` - ----------------------------------- ----- -- 1 .� I T Y i DICER/ce chevron froduc-ts Co. (Attn- David Lyons i PHOS (-425)842 -438 I c I c`ocnRAcroR NAME javidgo Construction , Inc. I PHONE 9 (S3o) 622- 1182- 0 9820 ---------------------------------------------------------------------------------------------------------------------------I I N T cwr>acrae AODRFss -4401 Sonja Gourt PlarcrvEllel a Lxc R 755898 I cIAss A A HAf. I IT _______________-_-_________--______________________________________.________..____________..____ ---I 1 R I INSURE rjt?tG Comrensatian Insuranu Fuhd I NONE-ccHP-P 273-2003 I ---------------------------------------I I C I onaN INNNaTIOR I I IT _____________________________________________________________________________________i-PHONE g___--_--- .---_---i 101 1 R ______________________________________________________________________________________________________________________________1 I I I PHONE 0 I ---IIIIIIIIIIIIIIIIIIilllllllllllll----------------------------------------------------------------------------------------------I 1 I TA3a ZD R I T3Eac SIZE I aaaucws sloReR CURRENTLY/PREVI o y I DATE UST INSTALLED 1 1 139- Bl 1 l2.iYJ� I r U, I 1996 I T 139- 02 I 12_y00 I Mi . L) I 19'16 i I A 1 39- t!) I IS -0492 1 &cC . UnI. 1 199ea IN139- 39- 39- 39- P 9-39-39-39-P2 1 I L I APPROV veo w2 xT Is) _DxsAe�ROPHO—J�, �1 A I (SEE WI ONE) I 19 1 pcnx REVIEWERStaus / «--IIIIIIIIIIIIIIIIIIIIIIIIIIIII II Illlllllltllllllllllilllllllllllllll I, ME IIII III IIIIIIIIIIIIIIII I 1 I APPLICANT MUST PERFORM ALL WORX IN ACCORDANCQ WZTH SAN JOAUUIN COUNl'Y ORDISWNCFS, STATE LAMS, ASID RULES AND RRGUWTI@1S OF I 1 SAN JOAQUIN COUNTY, ENVIPOSAR2ETAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY I I THAT INTHE PHEFOF.WNCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO I BECOME SUE.SECT N WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACNR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 1 FOIJ/JwING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS I$=, I SHALL EMPLOY PERSONS SUBJECT TO I NJRKER'S CCNEPENSATION LAWS OF CALIFORNIA." ' 1 J1 p J ��/ ~ TIME A DATE 7 21 APPLICANT`B SI@RIITURE: �1 i6r Cho/ran 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 and date below. Name RHLlka>fMn &OUP. Inc.Address 15.40 Arnold Dr. 0110 hartirkdePhone# 925-313-1700 Signaturint for Gl�.re.-, 014553 ex lob ��v v EH230038 1 (revised 1/31/02)