Laserfiche WebLink
F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />ENVIRONMENTAL HEALTH DIVISION <br />* APPLICATION FOR UNDER TANK RETROFIT, TANK LINING, OR PIPING Ro PERMIT <br />IS PERMITEXPIRES90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />X TANK REPAIR/RETROFIT _TANK LINING X PIPING REPAIR <br />EPA SITE 0PROJECT CONTACT 3 TELEPHONE M <br />eomay-j r *�vy- <br />FACILITY NAME FRANK' S FOOD MART #1 <br />ADDRESS 2072 W. YOSEMITE, MANTECA, CA <br />CROSS STREET AIRPORT WAY <br />OWNER/OPERATOR <br />FRANK'S FOOD MART — <br />CONTRACTOR NAME <br />PHONE # '_} Iqq 4-12_ <br />PHONE <br />72. - <br />PHONE i <br />X09 - 9 <br />PHONE 0 209 931-1828 <br />CONTRACTOR ADDRESS P.O. BOX 304875 CA LIC SON FILE I <br />CLASS ON FILE <br />INSURER ILE WORK.COMP.# ON FILE <br />OTHER INFORMATION <br />0 PHONE <br />R <br />PHONE M <br />TANK 10 N TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- 1 '� --0 10 , 000 GALLONS PREMIUM UNLEADED UNKNOWN <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39 - <br />III <br />P <br />L APPROVED _` APPROVED WITH CONDITIONS) _ DISAPPROVED <br />A c , (SEE ATTACHMENT WITH CONDITIONS) // o <br />N PLAN REVIEWERS NAME �'LGATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL 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 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE <br />BILLING INFORMATION: <br />TITLE DATE G-9� <br />Indicate the responsible party to be billed for additional PHS-EHD 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 must acknowledge this responsibility for <br />the billing by signature and date below. <br />Name CRISP PETROLEUM ENVIRONMENTAL <br />Mailing Address P.O. BOX 30487 STOCKTON, CA 95213 <br />Day Phone Number_ ( 2 U 9) 9 J 1— <br />�a <br />Si <br />6jza arc � � � ,�- . <br />EH 23-0038 � � .�� .� � a.t� � <br />, <br />/4)L47t <br />