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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT OR PIPING REPAIR PERMIT <br /> ThIS PERMIT EXPIRES 90 DAYS PROM THE APPROVAL DATE Do NOT WRITE IN ANY SHADED AREAS INDICATE PERMIT TYPE BELOW <br /> TANK RETROFIT PIPING REPAIR <br /> A SITE 4CAL002118208 PROJECT CONTACT & TELEPHONE # Bob Oliver 925-417-7405 1 <br /> AI raCILITY NAMEAT&T _� PHONE # <br /> C I .ADDRESS 110 West Turner Road, Lodi, CA I <br /> z <br /> L CROSS STREET Woodhaven Lane <br /> T I OWNER/OPERATOR I PHONE 9 I <br /> YI AT&T I {888) 835-5347 1 <br /> C CONTRACTOR NAME Kvaerner Aronson, Inc. PHONE # (916) 631-1646 <br /> K CONTRACTOR ADDRESS 11297 Colonia Rd.,Rancho Cordova I CA LIC #592010 I c:.AssA BC-10 HAZ I <br /> T <br /> R I INSURER National Union Fire, Rancho Cordova, CA, 95670 14ORK COMP #PAWC2179955 I <br /> A <br /> C I OTHER INFORMATION I I <br /> T <br /> O I I PHONE # I <br /> R <br /> PHONE # I <br />— llllllllillllllllf n Illilll!!I <br /> TANK � TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE JST INSTAL..ED <br /> 39- T02 oOt7 I�lesel - _I I <br /> T I 39- <br /> A I 39- I I <br /> N 139- I 1 I <br /> x l 39- I I I <br /> 1 39 39- <br /> I I I I <br /> P]111lIIIIIIIIIIIIIl11111111llltIttlll11111111111111111111111li, ill (�Ilol`141�11111111111[ilii!illifillltllllllllltl111111111111111 <br /> I APPROVED APPROVED AITH CONDITIONISI DISAPPROVED 1 <br />*1111 <br /> ATT WIT'{ CONDITIONS <br /> REVIEWERS NAME Vr DATE1111I1III 111111111111111111111111111111111i111i1 11111111 Illlilll11111111111111Illilll11111111111111i1111111111111111 <br /> APnr,ICANr MUS^ MERFCRM ALL WORK =N ACCORDANCE 4ITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND ZLLsS .AND AEGULATIONS 7F <br /> SAN JOAQUIN COUNT" PUBLIC HEALTH SERVICES OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWIVG _TCERT,-Y THAT IN I <br /> THE PERPORKANCC OF THE AORK FOR dHICH "'HIS DERMIT IS ISSUED I SrU►L. HOT EMPLOY ANY PERSON IN SUCH A MANNER AS ^O BECOME I <br /> SUBJECT TO +CORKER S COMPENSATION LAWS Of CALIrORNIA • CONTRAC'OR S HIRING OR SUBCONTRAC-ING SIGNATURE CERTI=IES -HE FOLLOWING I <br /> 'I CERTIFY THAT .N THE PERFORMANCE OF THE WORK rOR 4HIC4 -HIS PERMIT IS ISSUED, I SHALL EMPLOY DERSONS SUBSEC- TO WORKER'S I <br /> COMPENSATION LAWS OF CALIFORNIA 11 <br /> APDLiCANT'S SIGNAT'JRE TTI) of Special DATE <br /> Nygren <br /> 1ILLING INFORMATION <br /> Cndicate the responsible party to be billed for additional PHS-F,HD staff time expended beyond <br /> 3ermit payment coverage per tank If the party designated below is different than the permit <br /> ipolicant, e g property owner, the party must acknowledge this responsibility for the billing <br /> 5y signature and date below <br /> 11297 Coloma �Zd hone number (916) 631-1646 <br /> rameKvaerner Az'onS address���i�ho cor av�p <br /> s.gnature <br /> Gary Nygren <br /> Go�� fio�5 <br />,H#0038 7 I <br /> �NvS <br /> -- U L. G/ST"^ Goy/ r.��GC cv �T� Sime <br />