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Mar 01 04 01:35p Fra-7en Hill 559FQ81467 p.2 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 34D 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 <br />+-----•--•---- <br />_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />f i EPA SITE a <br />PROJECT CONTACT 6 TELEPHONE # Bob Hill 559-688-2977 ; <br />- - - - - - <br />i F ! FACIL;TY NAhN � <br />Food 4 Less PHONE # <br />A• -------------------------------------------------------------- 209-483-2342 <br />C i ADDRESS -------------- <br />1 <br />- -------1 ..___. ----- -----.3 •-___ Manthey Road Stockton, CA 95210 <br />-------------------------------- <br />L ; CROSS STREET ••••._..-! <br />I ---------------­- an rolyWeston Road <br />-------------------•--------------•----•----•-- <br />T OW <br />i <br />i NER/OPERkToa I PHONE # <br />IY; Dennis Cove 559-483-2342 ! <br />-----•-----•--------------• <br />i --------------------------- <br />C ! DCR�'7RACTOg NAME--------------------------------------------------------- <br />_ ! <br />1 D -------------------- Fran; en -Hill Corp - 1 PHONE # 559-688-2977 <br />.. ---- ' <br />! N ; COA•77tACI'OR AINJRE55 - --•--------------------•---•--; <br />1100 North J Street 1 CA LIC o 304147 1 'Ass A-B <br />.---_.-------------•--------------••----••---------------•---- ------------•----------------- <br />R � 1NS• f <br />A ;-.._eta;e_•Com ensation_ Insurance. Fund._ i wm"'cOMP.a 442010802 <br />; C i MER:NFORMATI ON _ _ .__: <br />T+_________ ___________Gulf_Underwriters Ins. Co. Liability I #GU2837916 <br />i 01 -•- <br />------------ _----- ---- X. --••-------- ----•------------•- <br />! R.______________.._-_..►Nalter_1VIor�nsen _Insurance_ Inc. I P�" 661-834-6222 ! <br />I I _ ___---------------------------------------------------- <br />Cell <br />__________y___-____--_-__--__-_-___ <br />Cell Phone - - - - <br />+---lil;;i;l;•1;;!;11---------- ; PHONE# 559-804-4610 : <br />: f runt xn " -----•-----•----•- ' <br />i 1 39- I TANK SIZE ' CHEN.I(JliS STJRED :JRRENTLY/PRBV:OCISLY ; DATE UST INETALLEp ; <br />T 1 39- <br />! A ; 39- <br />39- <br />39- <br />39- <br />1 <br />9-39-39-1 i 39- <br />-•-i ;1;;1!;;;i;;;11i!;;;111191;;illflll;;i;i;li;;;ll;;lf;;l <br />i P ; <br />APPROVED �— APPROVED WITH C0NDIT�ON:v 1 <br />i A �- =APPROVED <br />PLAN REVIEWERS <br />(SEE ATTAC}p�MM KITH CON-01TIONS) ' <br />N NAVE - I <br />•'" DA <br />i <br />APPLICAXT MUST PERFORM ALL WORK IN ACCORDAIICr WITH SAN J <br />OA <br />SAN JOAOJIN COUNTY, ENVIR01.'N,EATJI, HEALTH DEp;,RVr7SI. OWNER ORNLILICENSED EITI'S SIGNACERTIFIES CO URry ORDATURE TE WS' D RULES AND REGULATIONS OF <br />£S 7'F!e FOL.IO'aING: ^I CERTIFY , <br />?e^RFO7t7••,AVCE OF THE WORK FQR W-4xCH I}CIS PERMIT IS ISSUED, I S'a1U NOT EHPC.OY ANY PERSON IN SUCH A THAT IN THE <br />8'•ChP` E SUBJECT TO WJR=,S QONPENSATION LAWS OF {�_FORNIA.• CD.%=ACTOR.S HIP.ING OR SUSCOVIRACT�NINNEGR � � 1 <br />i FOZZOWING: •I CERTIFY THAT IN THE PERFORMANCE F K SIGNATURE CERTIFIES THE ; <br />0 ORK FOR WHTCH THIS PERMIT IS ISSUID, I SHALL EMPLOY PERSONS SUBJECT M , <br />CU!.PENSATI(IN LAMS OF CALIFORNIA. I I WORKER S <br />APPLI(AAZ"S S:'ZiA:VRE: l ' <br />O <br />____________________ <br />---------- ---------------­--------- ------------------------- !!! F/ V <br />BILLING INFORMATION; <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 />I" 1e Address <br />114 <br />hone # <br />