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i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 i . <br /> Telephone ; (209) 468-3420 Fax * (299) 468-3433 <br /> • i <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES IBD DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW; <br /> O TANK RETROFIT p PIPING REPAIR/RETROFIT f] UqC RQPAIRNWROPIT ❑ COLD STARTlEVR UPGRADE 1 <br /> F EPA Site # Pfojeot Conlaot & Telephone # EmIly Crain 916.371 .2380 <br /> A <br /> Facility Name Kwik Sery Esoalon Phone # <br /> I Address 2501 Jackson Ave , Esoalon <br /> G <br /> t Cross street <br /> Y Owner/Operator z, RA tC Phone 0 <br /> p Contraotor Name EZ Maintenance Phone " 916 371 2380 <br /> N ContraotorAddrees (DO l3oX 933 W Sao , 95691 CALlo1/ SAA attached Class <br /> T <br /> R Insurer See attached work comp # I <br /> ° ICC Technlalan's Name See attached Expiration pate J <br /> T <br /> ° IOC Installer's Name Explrallon Date j <br /> R i <br /> Tank syetem work area Tank Size Chemloais Stored Currently Date UST <br /> (1,r, OT pfpinp Sum Ut twe dolor. UDo ll11 alo.) Installed I <br /> T 87 tank - drop tube 12030 UNL <br /> A 91 tank - drop tube 8016 UNL <br /> I( DSL tank - drop tube DSL i <br /> I <br /> P ❑ Approved 17 Approved with conditions Q oleapproved r i <br /> L ((See Atlaohment With Condi (lons) <br /> N Plan Revlewers Name ' �`1(1 �1 � p Dote <br /> APPLICANT MUST PERFORM ALL WORT( IN ACCORDANOE WITH SAN JOAQUIN COUNTY ORDINANCES, &TATE LAWS, AND RULES AND REGULATIONS OP BAN i <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LIOENOED AGENT'S SIGNATURE 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 99COME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA,` CONTRACTOR'S HIRING OR SUROONTRAOTING SIGNATURE CERTIFIES THE FOLLOWING; 'I CERTIFY <br /> THAT IN THE PERFORMANCE of THE WORK FOR WHICH THIS PERMIT i& ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF OAtIFORNIA" <br /> pllcanl18 Sipnaluro <br /> � TiUe r"T , ea Date <br /> i <br /> BILLING INFORMATION , <br /> Indloate the responsible party to be billed for additional EHD eteff time expended beyond permit 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 bllling by signature and date below, <br /> }} <br /> NAMEtC \I (OA � �L. � �G' I tJ V\ TITLE PHc)NrzV <br /> ADDRESS � �� <br /> I <br /> SIGNATURE - f , DATE, I ZCJc' I <br /> 2 <br /> 151-12300313151-12300313 (ravised 12• ii •1G) <br /> I <br />