Laserfiche WebLink
FROM OIL EQUIPMENT PHONE NO. : 209 7545726 Dec. 11 2001 02:17PM Pil <br /> rWIRDNMENIAL WEAI.TN DIVISION <br /> APPLICATION FOR UNDSRGROIM TANK RETROFIT. OR PIPING ASPAZA PERMIT <br /> THIS PSRMIT EKPIREE 90 DAYS FROM THE APPROVAL DATE, <br /> DD NOT WRITE IN ANY S'WADED AREAS. LNDIGTS PE2'N1i TYPE 35LOW <br /> TANK RETROPIT _ PIPING REPAIR <br /> EPA SITE 9 CAC002357743� PROSECT CONFACT a TXLEaWONE 'Keith A. Tallia 209-754-1808 <br /> PxDNe ' 209-931 -6048 <br /> P FACILM NAME 3 palms Grocer - <br /> Ai <br /> C onx" 6732 E Waterloo Rd Stockton CA 215 <br /> I ) I <br /> L CRDSS STREET Fairchild Rd. <br /> I 1 "ONE <br /> " 209-931 -6048 i <br /> T I OWNER/OPERATOR Rudy Mendonca I <br /> Y1 PHONE ° 209-754-18 <br /> c coNTRACfOR NAME Oil E ui merit Service <br /> 0 1 CA LIC 9 323417 1 —` g A Raz C10 C211,C57 <br /> N CONTRACTOR AS3D0.E5E p,p, Sox 950 <br /> T I WORK.cona.' 2 6 7 <br /> R IMsaRER State Com Ins. Fund <br /> A I <br /> C OTHER INFORMATION ' <br /> T I PHONE A <br /> 0 I i <br /> R I PRONE a <br /> �IIII111111111111111111111111", TANK SIZE CR1MICALS STORED CUR ENTLY/PREVIOCSLY DATE UET INSTALLED <br /> TANK ID M i- <br /> 1 I <br /> ly. J <br /> 39- <br /> 111111 I11 111 111 1111 1111 11 11111 111111 11111 111111111111 1111 1111111 11111 11111 ���� 11111 1111 Illilll <br /> L <br /> APPROVED _ APPROVED WITH CONOITIONM DISAPPROVED <br /> � <br /> A (SEE ATTACFMENI WITH CONDITIONS) <br /> DATE <br /> N PIAN REVZSWER5 NAME <br /> —A111111111111111111111 1111 111 11111 1111 111111 11111 11111 111111 1111111111111 11111111111 111 1111 11 11 11111111 <br /> MUST pERPORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COON:Y ORDINANCES, STATE LAWS. ANO R"I-s AND >eOU[%TIONS OF <br /> APPLICANTAQUIN COUNCY FWLEC WEALTH SSRVTCSS. OWNER OR MUNI= AGRNT'S S10NATURE CERTIFIES THE POLLOWI.MC: 'I OERTI PY THAT IN <br /> SAI I <br /> THE OAQU,MANCE OF THE WORK FOR WHICH 2HI5 PERMIT Is ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MAPPER AS � 9ECOME I <br /> SU&TECT 1'0 WORKER'S COMPENSATZNWN LAWS <br /> OF OTNE WORKOP ICH'THIS PEPMITHI SIM OR SUEDS�CS �NPLO[LGHATv--- CERTIFIES 2EFSO:IS SUE.TEI-1 TO -01MR-S{I I <br /> 'C CERTIFY :'HAT IN THE P / , <br /> COMPENSATION LAMS OP IFO .I <br /> TITLE Agent DATa 7/23/01 <br /> APPLICANT'S SIONA E: <br /> r A. T is <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional pHS-EHD staff time expended beyor <br /> permit payment Coverage per tank. If the party designated below is different than the perai <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the bii'ir <br /> by signature and date below. <br /> Keith A. O. Box 950 hone number 209-754-1.806 <br /> Name addre <br /> 95249 <br /> Signature <br /> eith A. lIa <br /> EH 23-0039 <br /> 1 <br />