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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUPi COUNTY <br /> 600 East Main Street.Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax: (209)465-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT E.xPIRFS 180 DAYS FROM THE APPROVAL,DATE. INDICATE PERMIT TYPE BELOW: <br /> d TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> Al EPA Site 9 Project Contact&Telephone# <br /> C Facility Name ?,CSIA1 KM:E 5ZRVICE CENTER Phone# 209-468-7063 <br /> 1 Address 1331 S. Nam Lane, Lodi, CA 95242 <br /> L <br /> T <br /> Cross Street Kettleman Ln <br /> Y Owner/Operator City of Lodi Phone 209-333-6800 <br /> C Contractor Name Vaqzeyf r4e% Ir1c: Phone# 209-367-4800 <br /> a <br /> T Contractor Address 2370 MoUjV o-Ci.-, 5tyl4, Ladi4 95240 CALic# 774802 Class-, '021.'D34,_t1140 <br /> R Insurer Statr�Ccnnp Iro,Fu*-Ld Work Come# 7.30-0000558 <br /> C <br /> T ICC Technician's Name Ce'sse Eerumen/ Eric Molgaard Expination Date 7/25 2014 <br /> o <br /> R ICC Instalier's Name Exairation Date <br /> _. <br /> ST <br /> 'rank system wont area Tank Size Chemicals Stored Currently Date l <br /> r,.a.67ponewmp,,r®aKoma.UbC:rr,,ex) Installed <br /> Tank #2 2,000 gam Un. Bade (81) on :le <br /> T _.. <br /> A <br /> N — <br /> K <br /> I <br /> I <br /> f -- <br /> p D Approved pproved with conditions L i Disapproved <br /> L �titachment With Conditions} <br /> i A _ <br /> N Plan Reviewers Name Date <br /> APPLICANT MU81 PERFORM ALL WORK IN ACCORDANCE V41TH SAN.!OAOUIN COUNTY ORDINANCES,ST ATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUN7`t.ENVIRONMENTAL HEALTH DEPARTMENT,OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN I <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 I <br /> TO WORKER'S COMPENSATION LAY/S OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUHCDNTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '9 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHIG THIS PERMIT IS ISSUED,,SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS i <br /> OF CALIFORNIA" <br /> ApolScant`e 5typa:ure ___ 46 Dale .....__.—. <br /> HI ING INFORMATION <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than tfte permit applicant,e.g property owner,the party must acknowleoge <br /> this responsibility for the billing by signature and date below. <br /> NAME;jnaepl- as , ba v tP_,pr(ze , (;e*Lesra.,Ma4U �W PHONE#_.L09 36 7-4800 <br /> ADDRESS2370 Ma rCirr, Sta4, Lodi.; CA 95240 <br /> SIGNATURE -^;+e -' - K� DATE t °7 ! !+L' /:4'e _ <br /> EH230038(revisers 07(22/t1J} <br /> 2 <br />