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ENVIRONMENTAL HEALTH DIVISION <br /> •y APPLICATION FOR UNDEOND TANK RETROFIT, TANK LINING, OR PIPING SIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X TANK REPAIR/RETROFIT _TANK LINING PIPING REPAIR <br /> EPA SITE # CAC000883048 PROJECT CONTACT 8 TELEPHONE # MIKE FLORES 1209) 464-8333 <br /> F FACILITY NAME E. F. KLUDT & SON, INC. PHONE #209-466-8969 <br /> A <br /> C ADDRESS 1126 E. PINE, LODI , CA 95240 <br /> I <br /> L CROSS STREETCLUFF AVENUE <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y STEVE KLUDT 209-466-8969 <br /> 0 CONTRACTOR NAMESTOCKTON SERVICE STATION EQ. CO. , INC. PHONE #209-464-8333 <br /> N CONTRACTOR ADDRESS 820 N. UNION ST. CA LIC # 309105 CLASS C61/D40HAZ <br /> A INSURER ALEXANDER & ALEXANDER WORK.COMP.# 80161762 <br /> C OTHER INFORMATION <br /> T <br /> 0 <br /> R PHONE # <br /> PHONE # <br /> 39- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> III 111111111111111111111111111111111111111111111 IIIIIIIIIIIIIIITF1 FiTnTrffl 11111111111111111111 IRTFIMITIMIT <br /> APPLICANT MUST PERFORMgn <br /> IN-AC RDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBSERV CES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE HIC THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMLA OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THEE THE WORK FOR WHICH TH S PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OFCAPPLICANT'S SIGNATURE: iKE ' P.fs TITLE �v-ih DATE z-I6-`14 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-END staff time expended beyond permit payment coverage per tank. If the <br /> party designated below is different than the permit applicant, e.g. property owner, the party mut acknowledge this responsibility for <br /> the billing by [signature and date below. <br /> Name L ,f Ki .L\ A u–�r,!— )F -S'73 bA S k t\�"– <br /> Mailing Address 4>.(�� <br /> Day Phone Number <br /> Signature <br /> EH 23-0038 <br /> 1 <br />