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APPLICATION FOR UNDERGG ND TANK RETROFIT, TANK LINING, OR PIPING REP ERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE AL DATE. DO NOT WRITE IN ANY SHADED AREAS �IiDICATE PERMIT TYPE BELOW: <br />_TANK REPAIR/RETROFIT _TANK LINING X' PIPING REPAIR <br />39- <br />T 39- <br />A 39- <br />N 39- <br />K 39• <br />39• <br />39- <br />P 1111 <br />L <br />A <br />N <br />11111111111111111111111111 <br />TANK ID # <br />EPA SITE #'GdPROJECT <br />jw 131 '111 <br />CHEMt94�roCURREN ViOUSLY <br />CONTACT $ TELEPHONE # <br />NICK CHRONIS <br />916 -421-1� <br />FA <br />FACILITY NAME <br />ARCO <br />�, . <br />T <br />PHONE 0 <br />fiTTTTTTITITTTTTTTTTTTTTiT <br />�TITiTTT1TTTTTTITT�>T'1T(ITTi1TT <br />1T� TTT�`11 iTT <br />TiTTiTTIfii1TITTTiTTfI <br />C <br />I <br />ADDRESS 2908 <br />BENJAMIN HOLT DR <br />STOCKTON, CA <br />L <br />I <br />CROSS STREET <br />PLYMOUTH ROAD <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />" <br />478-5552 <br />C <br />CONTRACTOR NAME <br />TRIANGLE INC OF SACRAMENTO <br />PHONE 4 916 421-1990 <br />0 <br />N <br />CONTRACTOR ADDRESS <br />P 0 BOX 231067, SACRAMENTO 95823 <br />CA LIC # <br />18355, <br />CLASS A <br />T <br />R <br />INSURER <br />WORK.COMP.# <br />A <br />pWC27232 <br />C <br />OTHER INFORMATION <br />T <br />0 <br />PHONE # <br />R <br />39- <br />T 39- <br />A 39- <br />N 39- <br />K 39• <br />39• <br />39- <br />P 1111 <br />L <br />A <br />N <br />11111111111111111111111111 <br />TANK ID # <br />TANK SIZE <br />jw 131 '111 <br />CHEMt94�roCURREN ViOUSLY <br />DATE UST INSTALLED <br />c '1�g�� <br />�, . <br />T <br />fiTTTTTTITITTTTTTTTTTTTTiT <br />�TITiTTT1TTTTTTITT�>T'1T(ITTi1TT <br />1T� TTT�`11 iTT <br />TiTTiTTIfii1TITTTiTTfI <br />APPROVE ✓ APPROVED WITH <br />5EE ATTACHMENT WI <br />PLAN REVIEWERS NAME -J <br />1111111111111 I I l l 111111 11 111illTl B I L I TTIT11 li'1 TTMI1 M <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIq <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED` <br />THE PERFORMANCE OF THE WORK FOR WHICH THiS PERMIT iS ISSUED, I <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRAC <br />"I CERTIFY THAT' IN THE PERFORMANCE OF THE WORK FOR WHICH THiS <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: <br />BILLING INFORMATION: <br />ION(S) _ DISAPPROVED <br />ITIONS) DATE_ <br />ITTII MITTTTTTTTiTt 11111 11111 1 1 1 1 1 <br />CITY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />T'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />%LL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />41T IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />At1 , .5 F-6 L" I-, P— <br />T I TLE <br />— <br />TITLE DATE 7-13-95 <br />indicate the responsible party to be billed for additionalfPHS-END staff time expended beyond permit payment coverage per tank. If the <br />party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for <br />the billing by signature and date below. <br />Name TRIANGLE INC OF SACRAMENTO <br />Mailing Address P 0 BOX 231067, SACRAMENTO, CA 95823 <br />Day Phone Number ( 916 ) 421-1990 <br />Signature / <br />EH 23-0038 2. �P� i--vJ- ✓G�'n �""� �'>� ��� <br />J <br />