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10/28/15 03:44PH BZ Service Station Maintenance 916-572-1050 p.02 <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />Z' <br />0 <br />N <br />T <br />R <br />A <br />T <br />0 <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />AilOUNTY <br />1868 E, Hazelton Ave., Stockton, Califol`nia 95205 OCT 2 8 2015 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRrS IW DAYS F140M THE, APPROVAL DATE. INDICATE PERMIT TYPE! 8111.0W: <br />0 TANK RETROFIT PIPING REPAIRRETROMT 0 UOC REPAIRIRETROFIT 0 COLD STARTIEVIR UPORADE <br />_EPA Site 9Project Contact & Telephone # <br />...... .... .. <br />Facility Name <br />Cross Street <br />Owner/Operator— <br />Contractor Nam <br />; r n ractor Andress <br />Insurer <br />ICC C T e q, h Ani cAj an's N a rat �ie <br />ICC Installer's Name <br />Tank system work area <br />li.o. 87 rq�ng wolp, 01 leak detedot, UDG <br />Plan Reviewers <br />Approved <br />L�hone <br />Phone # <br />Llc fttriose v <br />�An=Lve—wo-A-�A-4,��_ Work Comp 0 <br />Expiration Date <br />Expiration Date <br />_6,`c`_U ST <br />tip Tank Size Chemit' als Stored Currently III <br />Installed <br />conditions Disapproved <br />9) <br />— e-) <br />WPLICANT MUST PERFORM ALL WORK IN ACCOROMCF, WlTqSAN JOAQUIN COUNTY-ORDINANC12,85, STATE LAWS, ANO RULES ANO RrX3ULAIIONS Off' SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNI R OR LICENSED AGENT'S $IGNATURE CERTIrIEG THE FOW.OWING� "I CERTIFY THAT IN <br />THE PERVORMANCE OF THV WORK FOR WHICH THIS PERMIT I$ ISSUED, I$HALL NOT EMPLOY ANY PERWIN IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S C 10 : LAWS OF CALIFORNIA,' CONTRACI*QRIS HjfjING OR SUSCONIRACTING $*NATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />M" <br />THAT IN T`HdOP�C�FW?� IE Or THE WORK FOR WHICHTI-IIS PERMIT IS ISSUED, I $"ALL EMKOY PERSONS 5Ij5jGCT TO WORKI_,R'$ COMPENSATION LAWS <br />01`4 MIPORNIA."rI <br />'%_/ i1/ BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional E1qD staff time expended beyond permit payment coverage per lank. if <br />the party designated below is different than (tie permit applicant, e.g. Properly owner, the party must acknowledge this <br />responsibility for the billing by signature and date below, <br />NAME J�Z'04 AL ft)4&AMAMKI7H0NE#, CW I <br />