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0 <br />• <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street Stockton, CaB%rsk 95242 <br />Tdepbane< (204) 468-3420 Fax: (7A9) 4611-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REP" PERMIT <br />TWe PERMIT E7{PIRES 100 DAYS FW N1 TME APPROVAL GATE. MWATE PERMIT TOPE BELOW: <br />TANK RE=o"rE j IPWG REPAJRJRETROtTT ❑IRIUDC REPAmROR T []MLDlEm UPGRADE <br />F <br />EPA Sib 8 Prged ConWlt d Telephone # Eft Janmen 7) 293-2M <br />C <br />Fvn2yrNwwTsscrd5hl4#88159 Phos,elE 389-1t�25 <br />I <br />L <br />Address35 North Che OWS Lens, Lodi CA <br />T <br />cnmsttsdmm SliIn <br />v <br />dw wgVenowTesmo Rdining b Melketlng # <br />c <br />CwtedwNsmeRSSE, Inc tfiara;If530241-1x75 <br />N <br />Con mkwAddress828 Twin View Blvd. Redding CA MW ;p 987228 Clew A. 6, CID, w <br />T <br />R <br />A <br />comp Compeny Wcomp 0010KRM12 <br />tnsurerDekle W" <br />T <br />=TedaYdads NamiJohn Jedwon Evwon Dde2ii =3 <br />R <br />ICC knuders NameiJohn Jackson EIIpYdon Dds51a=13 <br />Tank system work eras <br />Tank <br />Chernicals Stored Cu Tw* <br />Debs UST <br />Metalled <br />p a eT vMw rano. IM Irk d�o� uM in. sw <br />T <br />88151 Premium(91) filtNapor <br />10, <br />gasoline <br />A <br />N <br />K <br />P <br />❑ ❑ Approved MAIN COnditkme ❑ Dl q*mved <br />LOft- <br />(See Alt chment With Cendlifons) <br />A <br />N <br />PIN RwWmn Nine <br />APPLICANT MUST PERFDM ALL WORK IN WMM SAN JOYYC M COUMV OWMAIMM, STATE LAWS, AND 1RULM AND REOULATION6 OF WAN <br />�ARIMsNT. OWNER OR UL D ASEIM SIONAfURE CERMM TME FOLLOWM Ik. T CERTIFY THAT NT!E PERFOraIANCE OF IM WORK FPERMIT IS ISSUED I SHML NOT E103UN ANY PERSON N SUCH A U MM At TO sEDOME SUBJECT <br />JOAGM COUNTY, ENVIR00A MAL F�= <br />TO wOR1 IMS COIa�8ATION LAMF�2 CONTP CfORS HIRMIO OR OLMOONTRACTING 8IGNATURE Ctm a M 1 THE FOLLOWING: I CERTIFY <br />TMT IN TiE PERFORM44M OF THE C FOR wHKE1 THo PERk11T rS ISSUED.18MML ErLOY Pt3WO SUBJECT TO WORNEWS COMPENSATION LAWS <br />OF CJWFORNLV <br />Ra d11 <br />Wil wbe the wponotb <br />the party deeignetad <br />responsi6illty Ibr Ills <br />.,Lv Lynn Fry <br />fflu-mw 114fCLIPReM11UN: <br />wily to be billed for additional EHD staff time expended beyond panni payment coverage per tank. K <br />Iw is dif emd than the permit applicant. ag. property owner, the petty must acknoM+ a fie this <br />by signeWre and Saba below. <br />VP <br />Vow Bund. Redd ltoAM96= <br />530241-1275 <br />