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4... <br />ENVIRONMEN'TAL'HEALTH-DEP'ARTMENT t".SAN J <br />PAQUIN COUNTY <br />' V`. 600 § 'St 1g0Rj Comma 45202 a` <br />_@kepELQe.`'(�09}.68-342Q .mss (209) 465-433 <br />ApPLI 'fid ;F DE GR ,UND $T4 A GE TAM RET IFIT O PIPING REPAIR PERMIT <br />r TWIS {RwRMiT `XPIRES 180. DAYS FROM'THE AQP •'DATE. INDICATE PERMIT TYPE BELOW <br />TANK, RETROIFIT Lf';PIPIN¢ REPAIR . &IT : u `' REPAI OFiT O' COW. TART UPG E <br />p <br />F <br />1wPA Bite #P. Contac & Telephone` <br />A ° <br />Facility Name! Arco -;Mow ate a Phone # 209 <br />'C' <br />Address M R� ` rop 95330 <br />Y <br />xpvmer/Op6rator Auburn 77Q'Inc <br />Phone* '209 <br />®.. <br />Cantractor Name Seriiice Station Testing -SST INC ; <br />Phone ($pg 465-5577 <br />N <br />T• <br />Contractor Add 'PO Box 31465 - ori, CARR 95213 ' CA Lic # X2520, .Glass` A B r C-1 0,20,36 <br />R <br />Insurer EXEMPT' <br />wont <br />T <br />ICCJg0niaa6`s Name 'Cad Wa' ne'M'end on 5262923} <br />Expirati®n Date 08/10/2014 ' <br />oItO <br />installers Name wA Expiration N/A <br />a.. <br />° Tarn s m YID .q.� (�+ GtiemiiIs 3to 'Date QST <br />° SlnlQ ecllZex ' !. y, t ile9d <br />0.0. 87 0*9 d� 91P , 112, ) <br />T" <br />4 <br />A <br />,N <br />®P <br />�.!APprnved C1 Appro conditions � D' pr+ovsd <br />L <br />,, <br />(S C®nditlons� :. <br />N <br />'Plan. Reviemoo Name:, <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SM J•.9AQUIN 06UNTY ORDINANCd. STA`I`D LAWS, AND RULES AND REGULATIONS OF SAN, <br />JOAOUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNSWOR,LIC A. SK3NA FlES THE FOLLOW : I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH`THIS PERMIT IS`ISSUED;' I SHALL NOT EMPLOY ANY P 'IN -SUCH A MANNER BECOME SUBJECT <br />ToWDRKER'3 COMPENSATION LAWS OF CALIFORNIA." 01::)11 C RS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING :; "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS P IT IS ISSUED, t SHALL EMPLOY PERSONS SUB,ECT TaWORKER'S-C SATIOPJ AWS <br />OF CALIFORNIA." ° <br />nc'• nature °^ -•- ' Tatler � A Agent � 11)27113 <br />e .BILLING,1WOFFTI N: <br />Indicatg the res,onsihle„pariy to be billed for addittorrgl EHD staff flume expended beyond permk•paym, pt coverage per tank. ; If <br />the.. party 0 ' hated below IS. d' nt than the permit 'applicant,,, e.g: property owner, : the party must ac lmowie+ oe this <br />respo ity for the billing by signature. and.date J)WoW,. <br />NAME Cart Wayne` Nendersgn , „TITLE Preside4: PHONE'#,w (209)467,7673 <br />ADDRE6i . PO �Ox 31325 - Stockton, CA, 05213 <br />• • 11127/13 `” , • <br />'NATURE ,.-- ; DAT. <br />. V ` Ef 1230035 (re42120109) r <br />