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R <br />..► r�rE� <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PT -PING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT PIPING REPAIR <br />EPA SITE #CAL002118208 PROJECT CONTACT & TELEPHONE # Bob Oliver 925-417-7405 <br />F FACILITY NAMEArr&rr PHONE # <br />A <br />c I ADDRESS 110 West Turner Road, I�Odi, CA I <br />I <br />L CROSS STREET WoodhaVen Lane <br />Z <br />T I OWNER/OPERATORI PHONE # <br />Y AT&T <br />(888) 835-5347 I <br />I <br />C CONTRACTOR NAME Kvaerner Aronson, Inc. PHONE #(916) 631-1646 <br />0 <br />N I CONTRACTOR ADDRESS 11297 Colana Rd. ,Rancho Cordova I CA LIC #592010 1 CLASS BC -10 HAZ I <br />T <br />R I INSURER National union Fire, Rancho Cordova, CA, 95670 I WoRK.coMP.# RMWC2179955 I <br />A <br />C I OTHER INFORMATION 1 <br />T I <br />0 PHONE # I <br />I <br />R 1 I PHONE # <br />— <br />TANK # TANK SIZE 1llllillltfliltltlllilltl' CHEMICALS STORED CURRENTLY/ PREVIOUSLY 1 DATE UST INSTALLED <br />TANK jTE <br />1 <br />39-_ t -7 t{ !- �(® 1_ f �cse%ta I piesel I I <br />T I 39- <br />A 1 39- <br />N 1 39- { I 1 1 <br />K 1 39- ' I <br />1 39-39- <br />�Illllillllllll{tIt111111I1111111111lI1tlIIIIIItlllllllls��.{i 1 I Iltl�{Illlllt111111Itttflllllitllfllttllllllltlllltlll111 <br />L I APPROVED —)C APPROVED WITH CONDITIONS) DISAPPROVED <br />A t ` �y $^ ATT WITH CONDITIONS) DATE <br />N ! PLAN REVIEWERS NAME <br />--III [111111111111111111111111 lttlt tliltltl ltillltlfftllltilttllitlltllltlltllllllltillll I1111111111t� <br />APPLICANT MUST PERFORM ALL WORK :N ACCORDANCE WITH SAN JOAQUIN COUN.'Y ORDINANCES, STATE LAWS, AND RULES AND REGUI.:,TT_ONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •- CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCI A MANNER AS TO BECOME 1 <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE. CERTIFIES �y FOLLOWZNG:I <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S I <br />COMPENSATION LAWS OF CALIFORNIA.• F I <br />(� J TIT <br />_LUirector of Special //Z3/%j'� <br />APPLICANT'S SIGNATURE: DATE <br />[-.a ry t�ivcYren <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br />permit payment coverage per tank. If the party designated below is different than the permit <br />applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br />by signature and date below. <br />NameKyaerner A122aggZaddress11297 Colonia Rd hone number(916) 631-1646 <br />Signature <br />Gary Nygren <br />EH 33-0038 ���-�vi�i�1G�!/�S�/4 jY>� !/•rr•�• St/S i"� <br />(.%. L _ ami/S�� J �iG7/'m�%jQ r �•��,� C!7 c �'j� � % �� <br />1 <br />