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11/23/15 11:52AM BZ Ser Station Maintenance 916-572-1050 P.03 <br /> EINIVIROXTA"NIMENHEALTH r":'EPARTMW(;F <br /> I VA V IVED <br /> SAN JOAQUIN COUNT: Y <br /> 1868 E. Hazelton Ave,, Stockton, California 95205 NOV 2 3 2015 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 ENVIRONMENTAL <br /> APPLICATION FOR UNDERGROUND STS GE TANK L49:AITLJ n[:0ADTAA[:&IT <br /> RETROFIT OR PIPING REPAIRPERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPIROVAL©ATT. INDICAT:v PrRMJT TYPE <br /> ,L)TANK R5TROFIT Q PIPING REPAJIVRETROF� N4�10C,REPAIRJRETRQ:FIT 0 COLD START/EVR UPGRADE <br /> F Tl�:7A:i�iteft <br /> .2r 'J <br /> oie—ci C—ontac­t&—Telephone# 17 <br /> A <br /> FacRity Name <br /> Phone W <br /> A� <br /> IL <br /> Cross Street L <br /> T <br /> Y Owner/operalift Ph <br /> Contractor Nafrle `'" •- <br /> Phone j <br /> N <br /> -Y'v Class <br /> T contractor Address -7 (f,"'2. <br /> CA Liq� <br /> R <br /> A <br /> L Work Comp <br /> T I Fc—Ti Name'ne- 7T1;7,7T­­—­­' <br /> Expiration Date <br /> Name <br /> JCC Installer's <br /> .ExpiratJon C1ate <br /> Tank system work area <br /> (I.e.81 PtpiMj.501p,91 101k diahQcW.u0c 1(2,otd.) Tank Size Chemicals Stored Currently Date UST <br /> installed <br /> L <br /> A <br /> N <br /> ................. <br /> K <br /> t <br /> Approved <br /> L .1 Pr1roved with QQntjjtionj LJ Disapproved <br /> A Xtlachrnarit With Conditions.1 <br /> e <br /> N <br /> Plan Reviewers Name,- Data <br /> APPLICANT MOST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNly ORDINANCES: STATE LAWS,AND RULES AND RC-(3 OF SAN <br /> JOAOVIN COUNTY. " 111(?Nhol NTA, <br /> 00-ARTMENT.OVVNFR Oil LICENSG.r)AGENT'S MGNATUnt!cCR-m--iFS THE POLLOWINO: *1(;VRTIFY TIJA <br /> iTHE fAJ;fjFOIRMANCE OF TtiC., 113� R M HTHIS PERMIT IS 188U!D,I SHAkA,NOT VMPLOY ANY PeRSON IN SUCH A MANN/„R AS TO BECOME SUBJEC"TIO <br /> 1WORKER'S COMPCINS BION j%0T �r <br /> ��'A CALIFORNIA.”RNIA." CONTRACTOR'S HIRING OR $(AXONTRAOTING SIGNATURE CERTIFIESTHt-�' FOLLOWING: "I CERT'IFY <br /> THAT'IN 1111E PERFOR 4ANC 0,L'F <br /> K I?QR WHICH THIS PrRMIT IS ISSUED,I',HALL EMPLOY PERSON$SUBJECT woftaR' <br /> vY <br /> OF CALIFORNIA." S COMPENSATION LAWS <br /> I�EL'Iiznnr Sinolkin) <br /> BILLING INFORMATION: <br /> Indicate the responsible Pai­00­6'e' bllled for additional EHO staff time expended tmyond permit payment coverage per tank. 11 <br /> the party designated below is different then the papff)lt applic,111t, 'e,g, property owner, the Party must acknowledge this <br /> red pansib'Jit •for the billing by signature and date below. <br /> C <br /> TITLE MiONE, <br /> AE)ORESS <br /> �A <br /> S S <br /> IGNATVIRC-.... <br /> 2 <br /> ................................................. <br />