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•��' ENVIRONMENTAL HEALTH DIVISION <br /> APPLIZATION FOR UNDERGROUND TANK UPGRADE, OR REPAm PERMIT <br /> APPLICATION FOR UDGRAOE,OR REPAI� PERMIT OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS fkOH THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPt tELOW: <br /> _X UPGRADE REPAIR <br /> EPA SITE / PROJECT CONTACT L TELEPHONE /Andrew E. A1tes 209-367-32.30 <br /> F FACILITY NAME Ti ger i pE / <br /> A <br /> C ADORES$ 927 Plack Diamond Way Lodi CA 95240 <br /> I <br /> L CROSS STREET <br /> I Cluff Avenue <br /> T OWNER/OPERATOR PHONE / <br /> Y <br /> Tiger Lines Inc 209-333-030 <br /> C CONTRACTOR NAME pJ� C Construction PHONE 1209-462-9211 <br /> 0 <br /> N CONTRACTOR ADDRESS .5637 N. Pershing, A3 Stkn. CA CA LIC / CLASS A NAZ <br /> T <br /> R INSURER State Fund WORK.COMP./ <br /> A J0630393 <br /> C <br /> T <br /> 0 - PHONE / 209-951-930 <br /> R <br /> PHONE / <br /> ANK <br /> uuuun0 4nnum <br /> ANK 0 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DAVE UST INSTALLED <br /> 39• _ in, nnn niPcol FnnT Al? <br /> 1 39• 70 nnn niae�al FU,A7 g,2 <br /> A 19- in, nnn nipsel gual az <br /> N 39- <br /> K 39- <br /> 39• <br /> D <br /> ' APPROVED APPROVED WITH CONDITION(S) �• DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> M PLAN REVIEWERS NAME DATE <br /> IIIIIillllllllllllilIII I till III IIIA <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER 04 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING! ^1 CERTIFY THAT IN <br /> THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "i CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.• <br /> APPLICANTS SIGNATURE: TITLE S aft U Director DATE •,319/93 <br /> SILLING INFORMATION! <br /> indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minfmLn permit payment per tank. <br /> If the petty designated below i0 dif •rent than the permit Applicant, e.g. Property owner, tha party must acknowledge this responsibility <br /> for the billing by signature and d to below. <br /> Name <br /> Melling Addren <br /> Day Phone Number ( ) - )298 <br /> Signature <br /> EH 23.0000 �7 <br /> n rp n rn <br />