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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205. <br />Telephone; (20 } 468-3420 Fax: (209) 4M3433 <br />At�PI_ICATifN l+CF UNCJERGRi)UNC� STc�RAG TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 OA.YS I?ROM THE HPPROVAL DATE. IbID1CATE PERMIT TYPE BELOW: <br />TANK RETROFIT n PIPING REPAIRIRETROFIT n UDC REPAIR/RETROFIT O COLD START/EVR UPGRADE <br />---- <br />RIL.LING INF(?RIv1ATiM <br />----- <br />- <br />EPA Site # � <br />Project Contact &Telephone # <br />�` _ <br />Facility Name George Kishida phone# 916-368-0603 <br />Address 1725 Ackerman Dr, Lodi 95240 <br />t <br />l <br />Cross Street <br />r <br />Owner/Operawr Phone # <br />W <br />Contractor Name_ SZ Maintenance Phone # 916-371-23$0 <br />Q <br />7 <br />Contractor Address PCS B0X 933, W .S. aC 901691 I CA Lick 4331 5g Class A B C-61 D40 <br />R <br />insurer see attached i <br />Work Comp # <br />T <br />ICG Technician's Name see attached — <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />- - <br />Tank system work area�7ank <br />Size <br />Chemicals Stored CtLrrenti y <br />Date UST <br />n o, rot Nptng Sump, N ink ammint, JOC lvd atc j <br />Installed <br />DSL 1 STP <br />T <br />A <br />�( <br />IN <br />K <br />_ <br />P <br />Approved ;% Approved with conditions %. Disapproved- <br />L- <br />(S�e Attachment With Conditions) <br />A <br />N <br />Pian Reviewers Name_ � �k0 tmm Nu_ Date. <br />_ <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL. HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 15$UED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SU8,IECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA!' CONTRACTbR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING "j CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PER17 IS ISSUED, I SHALL EMP40Y PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Margafet Smith, Compliance Testing Coordinator 2/3/2026 <br />Aj)OIcant's <br />indicate the responsible party to be billed for additional HD sta.fr time expanded beyond permit paymentcoverage par tank, If <br />he party designated below is different than the peo; it applicant, e,g, property owner, the part <br />r <br />y must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME, C.-+eome.Klshi�a_TITLE PHONE <br />/t; <br />i <br />ADDRESS 1725 Ackerman Dr, Lodi 95240 <br />XGNATI. <br />EFL230038 {revised 12-1115} '? <br />