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FROM : OIL EQUIPMENT PHONE NO. : 209 7545726 Nov. 16 2001 08:20RM P4 <br /> • RNVIRONNENTAL WSAI.TH DIVISION <br /> APPLICATEON FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERNIT REVERES 90 DAYS FROM TNR APPROVAL UTS. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PEMT TYPE FELON: <br /> TANK RETROFIT PIPING REPAIR <br /> EPA s= P CAC002357743 PROJECT =ACT A TELEPHONE {Keith A. Tall ia 209-754-1808 <br /> F FACILITY NAMR 3 palms Grocer PHotts P 931-6046 <br /> A <br /> c I ADDRESS 6732 E. Waterloo Rd. Stockton CA 9521 <br /> x <br /> L I CROSS sTRSST Fairchild Rd. <br /> T I OWNSR/OPSRATOR I PECNE P I <br /> YI Rudy Mendonca I 209-931-6048 I <br /> e eoNTRAcrOR NANe 011 Equipment Service PRONE tl T � 209-754-180$ I <br /> W I COIRRACIOR ADDRESS P.O. BOX 950 I G LIC tl 323417 I CLASS A,Haz,C10 C211,C57 <br /> T <br /> R INSURER State Com. In$. Fund I WORK.CONPA 2 1 <br /> A <br /> C OTW R INVOPNATLON I <br /> T <br /> 0 ( I PHONt A <br /> R I PHONE { <br /> 1111111111111111111111111111111 <br /> TANK I❑ Y I TANK SIZE CY'Nxr+,e STORED C'JRA ENTLY/PRSVxOCSLY I DATE UST INSTALIrO i <br /> T I9 i I <br /> A ]9 , <br /> R I9• I I t I <br /> � IS. � 1 <br /> ���� � � � � IIIIIII►(f11111111111 11111111111111 � II1111111111111 1111111111111 ffl7-I <br /> L �. APPROVED RPPROvEO WITH CONDITIONIS) DISAPPROVED ' <br /> A' (SEE ATTACHMENT WITH CONDITIONS) ��y9 <br /> FLM*RM <br /> II EUCAS 1 111DATE <br /> APPLICANT MUST PSRFORM ALL WORK IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES, STATE LAWS, ARD RCLIS AND RE-D ,70NS CF I <br /> SAN JOAGVIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LYCENSED AGENT'S SIGNATURE CERTIFIES THE POLLONING: 'I CERTI„ THAT IN 1 <br /> TER PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NC[ EMPLOY ANY PEEM IN SUCH A :A.NNER AS TO a9COME <br /> SUBJECT TO WOREBR'S COMPENSATION LAWS OF CALIFORNIA.'// CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATJPE CERTIFIES T'?C POLLOWI4G,1 <br /> 'i CERTIFY TEAT Ett TMB R OF THE WORK /vHICW,THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORMR'$ I <br /> CCNPENSATYON LAMS OF IFO 1 <br /> APPLICANT'S SIGNA %: TITLE Arent DATE X23/01 <br /> t A. T a <br /> BILLING INFORMATION! <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br /> permit payment coverage per tank. If the party designated below is different than the permit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the biline <br /> by signature and date below. <br /> Keith A. P. O. Box 950 <br /> Name addre hone number 209-754-1808 <br /> - 95 49 <br /> signature � <br /> e <br /> ER 23-0038 <br /> 1 <br />