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,. ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNU% ,AOGHD TANK RETROFIT, OR PIPING REPAIR PERMII`i <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. W NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _TANK RETROFIT _ PIPING REPAIR <br /> EPA SITE N CACO02357743 PROJECT CONTACT i TELEPHONE %Keith A. Tallia 209-754-1808 <br /> F FACILITYNAN6 3 Palms Grocer PHONE ' 209-931 -6048 <br /> A <br /> C ADDRESS 6732 E. Waterloo Rd. , Stockton CA 95215 <br /> I I <br /> L I CROss sTREET Fairchild Rd. <br /> T l OWNER/OPERATOR Rudy Mendonca i PHONE R 209-931 -6048 j <br /> Y <br /> CCONTRACTOR NAME Oil Equipment Service I PHONE x 209-754-1808 <br /> N I CONTRACTOR ADDRESS P.O. Box 950 CTA L1C N 323417 I cL ss AIHaz C1 0 C211,C57 <br /> . . <br /> T <br /> �zNsvAER State Comp Ins FORKCOMPP <br /> Fund 265057 _ <br /> A <br /> C I OTHER INFORMATION <br /> T <br /> 0 1 I PHONE N <br /> R I PHONE R <br /> TANK <br /> �IIIIIIIIIIIIIIIIIIIIIIIIII <br /> TANK ID N TANK Si26 CHEMICALS STORED CJRAENR'LY/PREVIOCSLY I DATE VST INSTALLED � <br /> T 139 I <br /> A I 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> PED <br /> 9- I <br /> N 39- I <br /> K 39- <br /> 39- <br /> 11111 11 111 II111 IIIIIII11111 111111111111111 1111111111 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br /> L APPROVED APPROVED WITH CONDITION(s DISAPPROVEDA (SEE ATTACHMENT KITH CONDI?ZONS) <br /> DATE <br /> N I PLAN-REVIEWERS NAME <br /> ---I111111111111111111111I1111I111IIII111111111IIII11I111111111II11IIIIiilII1111IilllIIIIIIIIIIII11111Ii1I111IIIIII IIII11I11111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDLNANCES, STAT LAWS, AND RULES AND RECJLAT_ONS CF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT LN <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 SIGNAT-JP= CERTIFIES THE FOLLOWING:I <br /> 'I CERTIFY THAT 3N TT OF THE WORK F ICH,THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CCMPENSATION LAWS OHE F IFO <br /> APPLICANT'S SIGNATftEz TITLE Agent DATE 7/23/01 <br /> /Kfaith AT&IIia <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 pe-:nit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br /> by signature and date below. <br /> Keith A. O. Box 950 <br /> Name addre hone number 209-754-1808 <br /> Signature 95249 <br /> e th A. lia <br /> EH 23-0038 <br /> 1 <br />