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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3RD FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, 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 />_TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+------ ---------------------------------------------------------------------------------------- <br />_________________________+ <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # Bob Hill 559-688-2977 I <br />--"-- <br />F 1 FACILITY NAME Food 4 Less 1 PHONE # 1 <br />1 A +------------------------------------- 209-483-2342_ I <br />I --------- <br />I A-----3434---Manthe-—Road Stockton CA 95210 <br />------------- <br />L I CROSS STREET Carolyn Weston Road <br />1 <br />________________________________________ <br />T I OWNER/OPERATOR PHONE # I <br />Y Dennis Cove i 559-483-2342 j <br />1---+------------------------------------------ <br />C 1 CONTRACTOR NAME Franzen -Hill Corp PHONE # 559_ -6.8.8-2977 1 <br />O------------------------------------------------ --------------------------- <br />N CONTRACTOR ADDRESS 1 <br />1100 North J Street CA LIC # 304147 CLASS A -B <br />I <br />--------------- <br />A i-INs"REttate _ComDensation__Insurance Fund ___ 1 WORK -COMP- # 442010802 <br />------------ --------------+-------------- <br />C I OTHER INFORMATION Glf trs Ins.Co.L.iabilit I <br />I T +--------------------- ----u-- - --Underwri----------------e- C ---y 1 #GU2837916 <br />IOL 1 <br />1 R ---------------------- Walter _Mortensen_Insurance Inc. '-PHONE <br /># 661-834-6222 <br />- - - ----------- <br />Cell Phone ; PHONE # 559-804-4610 <br />11111111111111111111111111111111--------------------------------------------------- <br />TANK ID # I TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY 1 DATE UST INSTALLED 1 <br />39- <br />T 39- 1 1 <br />A 39- 1 1 <br />N 39- <br />K I 39- <br />39- <br />39- <br />P <br />9 39-P ; 1 <br />L I APPROVED APPROVED WITH CO TON( DISAPPROVED <br />(S TTACHMENT T IT NSI <br />fs/!//// <br />N I PLAN REVIEWERS NAM DATE 1 <br />I <br />; APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF I <br />1 SAN JOAQUIN COUNTY, ENVIRONIdENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOI.IOWING: "I CERTIFY ; <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TU ; <br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO I <br />COMPENSATION LAWS OF CALIFORNIA." 1 <br />I <br />I <br />I <br />I <br />I <br />O <br />APPLICANT'S SIGNATJRE: TITLE DATE � 1 <br />I <br />--------------------------------------------------------------------------------------------------------------------------------- <br />BILLING INFORMATION: <br />THAT IN THE <br />WORKER'S <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name �Q AddressAVILA 4L,,kA Sa PhoneS-6 t) i, <br />