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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNT' <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209 ) 468-3420 Fax (209) 468 -3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT G PIPING :REPAIRIRETROFIT ❑ UDC REPAIRIRETROFI011 0COLD STARTIEVR UPGRADE <br /> EPA Site # Project Contact & Telephone # Ernily Crain 0066 371 -2380 <br /> Facility Name George Kishide Phone. # 209-368-0503 <br /> L Address 1725 Ackerman Dr , Lodi <br /> i Cross Street MaxWell St <br /> T _ <br /> Owner/Operator 640:0�e - % 14 t k 06� t fk-r L. Phone. l# <br /> Contractor Name BZ Maintenance Phone # <br /> N Contractor Address PO Box 933 , W Sacramento CA t,io # t see attached Class <br /> R <br /> A Insurersee attached Work Comp # <br /> _ <br /> T ICC Technician ' s Name see attached Expiration Date <br /> ft ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals : Stored Currently Date UST <br /> (,,e. E7 pip aq Pune, 61 Isak dolectar, UDC 11Z .010-) Installed <br /> i T DSL _ 12000 <br /> A DSL 3000 <br /> N <br /> K <br /> ApprovedApproved 'with conditions ` Disapproved <br /> L 4See:Attachment With Conditions) j <br /> A <br /> N i <br /> Plan Reviewers Name Data I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH $AN' JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY; ENVIRONMENTAL HEALTH DEPARTMENT. .OWNER OR LICENSED AGENT'S SIGNATURIr CERTIFIES THE FOLLOWING. "i CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMiT iS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA," CON'TRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA," `'�-r.,.`'� / <br /> APpticant's Signature - jrg' 5t � fes` •., bale <br /> BILLING INFORMATION . <br /> Indicate the responsible patty to be billed for additional EHD staff time expended beyond ipermit payment coverage per tank, if <br /> the party designated below is different than the permit applicant, e.g , property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date,below. <br /> (NAME t:�1� t!lt : lt4c; TITLE PHONE # <br /> ADDRESS �. ue <br /> SIGNATURE DATE <br /> EH230038 (revised IZI 1 •i s? 2 <br />