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*er <br /> 5/27/2001 13:57 209468. 3 FIFTH FLOOR PAGE 02 <br /> .. R.,.�:...:wiz::.,.• :i...:_.... .,.�___... <br /> APPLXCATXON FOR UNDERGROUND TA= RETROPTT, OR P121UG RSPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AR-EAS. INDICATE PERMIT TYPE SSLOWe <br /> TANtt RE•CROFIT PIPING REPAIR <br /> EPA SITE 9 PROJECT CONTACT a?=MP9002 # <br /> T> <br /> FACILITY NAME QU11< 5?DP MA•21t.E7-6 ,l# 12 PHONE 9 ,209) 823-7628 <br /> A <br /> CI ADDRESS <br /> I Nj4TtLh4`,_ <br /> L I CROSS STREET I <br /> Y <br /> T 1 OWNER/OPS-BATOR Q,U 1 KST-DP MARKETS, 14C-. <br /> - I I T #510, 4*5.22b�5 I <br /> 71 CONTRACTOR NAME TRIAsetbt_E 6WV112oM,41&47AL., j"C. PRONE it (818')940-7020 <br /> 0 <br /> T ; CONTRACTOR ADDRESS 2525 W. SUP-®A til K O LVD. � CA LIC 0 ( CLASS I <br /> BUIESA49, dA . <br /> R I INSURER I WORK.CoMP.A I <br /> A <br /> C ' OTHER INFORMATION E <br /> D I I PRONE <br /> R �.-..----------- --- -- - —i <br /> —�1ltlltltlllttlllllllllt11111I1# I Pxoxs 9 I <br /> TANK ID # TANK SYzb CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> ] 39- <br /> I 1 I <br /> T ] 3.9- <br /> 39- <br /> 3 5- <br /> 9-39-39^ J I <br /> K ] 39- 1 ( I <br /> l 39- <br /> -�IItIl11i11111t1IIIIIIIII I fill IIIIIIIIIII I IIIIIIIIII Ifill[fill 11111 liffliflill ] 11111111111iiiiiiiiiiiiiiiiiiiiilifilifililI <br /> L ] APPROVED Y APP OVED (dI'II3 CONDITION(s) DXSAPYR�D <br /> A I CiM£N± WITH CONDITIONS) <br /> N ] PLAN REVIEWERS NAME DATE / V' <br /> —I 11111111111IIl1IIII t1fill 111111111 IIII I I IIIIIII illll III lllllllt1111111tltttllliltl11111111111 11111]11111111111 ifIIIifI <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY O?J3YxANCES, STATE LAWS, AND POLES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC REALTY_ SBRVICCS. 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. ; SRAL,L NCT PLOY ANY PERSON IN SUCH A :TANNER AS TO BECOME I <br /> S=YCCT TO WORKER'S COM?£NSaTION Law$ OF CALIFORNIA." CONTRACTOR'S BIR:YG OR SUBCONTAACTING SIGNATun CERTIFIES TaE FOLLOW:NG:I <br /> I CERTIFY TN—T IN THE PERFORMANCE OF TRE WORK FOR WHICH THIS PSRMIT 15 ISSUED, I SHALL EMPLOY PERSONS SL13JECT TO WORKER'S 1 <br /> COMPENSATION LAWS Of CALIFORNXA.' A <br /> APPLICANT'S S:GNATURE: . A • TITLE /+DM I AI/S r'2ATDP— DATE (o^Z8^D I <br /> I <br /> BILLING INFORMATION: <br /> indicate the responsible party to be billed for additional PHS-EHI) staff time expended beyond <br /> permit payment coverage per tank. If the party designated below is different than the perm-t <br /> applicant, e.g•. property owner, the party must acknowledge this responsibility for the billi C <br /> by signature and date below. <br /> TR►A'jfi-te 2526 w. 13k NC 6t-1/b <br /> Name E0/1201VA4&M1-,1A1C.address BUR-64e19.04. 91SAS' phone number j r )?40-7.020 <br /> SiSnature < .� <br /> EH 23-0038 S <br />