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7 <br />4 APPLICATION FOR UNOERG TANK RETROFIT, TANK LINING, OR PIPING REPa1 <br />THIS'PERMIT EXPIRES 90 DAYS FROM THE A DATE. DO NOT WRITE IN ANY SHADED ARPa1rtKn�� <br />EA LATE PERMIT TYPE BELOW: <br />TANK REPAIR/RETROFIT TANK LINING X' PiPING REPAIR <br />I�, BiLLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD 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 />TRIANGLE INC OF SACRAMENTO <br />Name_ - Mailing Address P 0 BOX 231067, SACRAMENTO, CA 95823 <br />Day Phone Number ( 916) 421-1990 - <br />Signature <br />EN 23-0038 li . Ile- Mi GBYt�r ""� v�i1�- vfi��� �'►"`(i� � �, <br />A •1� �� � e'er" e� <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # NICK CHRONIS 916 421-1990 <br />F <br />FACILITY NAME ARCO <br />PHONE # <br />A <br />C <br />ADDRESS 2908 BENJAMIN HOLT DR STOCKTON, CA <br />I <br />L <br />CROSS STREET PLYMOUTH ROAD <br />i <br />T <br />OWNER/OPERATOR <br />PHONE # 478-5552 <br />Y <br />C <br />CONTRACTOR NAME TRIANGLE INC OF SACRAMENTO <br />PHONE # 916 421-1990 <br />N <br />CONTRACTOR ADDRESS P 0 BOX 231067, SACRAMENTO 95823 <br />CA LIC # 183550 <br />CLASS q <br />T <br />R <br /># WORK.COMP. <br />INSURER PWC272324-02 <br />A <br />C <br />OTHER INFORMATION <br />T <br />0 <br />PHONE # <br />R <br />llktt <br />1111111111111 { { 1 { 1111111111111 <br />TANK ID # TANK SIZE CHEM D CURREN ViOUSLY DATE UST INSTALLED <br />39- <br />T <br />39- <br />39- <br />A <br />i <br />39- <br />---r1�+ <br />N <br />K <br />39-r <br />39- -�s- <br />iTiiTTiT imiIiP <br />IIIIiTfiTf11TT1iTiiilililTlTTi <br />L <br />A <br />APPROV WITH CONDITION(S) _ DISAPPROVED <br />tAPPROVED <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME1 <br />1 <br />I1IIiiIII1III1IIIIIIilifII I1111Ii(iI111�l 11111111]ITiiiIIT]1IIlliiiiliiTlTilIII!IiIiIl&Ili I1111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <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 CALIFCRNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT' IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." Zj C! , JC E:.6y� E,4t C V K'E <br />'V <br />APPLICANT'S SIGNATURE: TITLE .� DATE 7-13-95 <br />I�, BiLLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD 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 />TRIANGLE INC OF SACRAMENTO <br />Name_ - Mailing Address P 0 BOX 231067, SACRAMENTO, CA 95823 <br />Day Phone Number ( 916) 421-1990 - <br />Signature <br />EN 23-0038 li . Ile- Mi GBYt�r ""� v�i1�- vfi��� �'►"`(i� � �, <br />A •1� �� � e'er" e� <br />