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ENVIRONMENTAL HEALTH DIVISION �® <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING 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 />EPASITE #CAL002118208 PROJECT CONTACT & TELEPHONE # Bob Oliver 925-417-7405 <br />F F FACILITY NAME AT&T PHONE # <br />c I ADDRESS 110 West Turner Road, Lodi, CA I <br />I <br />L I CROSS STREET Woodhaven Lane <br />T 1 OWNER/OPERATOR I PHONE # I <br />YI AT&T 1 (888) 835-5347 1 <br />C CONTRACTOR NAME KvaernerAronson, Inc • PHONE #(916) 631 -1 646 <br />0 <br />N 1 CONTRACTOR ADDRESS 11297 Color Rd. Rancho Cordova i CA LIC #592010 1 =msA BC -10 HAZ I <br />T <br />R I INSURER National Union Fire, Rancho Cordova, CA, 95670 I woRK.coMP.# RMWC2179955 I <br />C 1 OTHER INFORMATION 1 <br />T <br />0 I I PHONE # I <br />R I PHONE # I <br />I <br />--it111111111111111tllltlltlllllli 1 <br />TANK T # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />1 <br />39- t �% l C.►[Q ' �r 4'i C►pr% I Diesel I 1 <br />T I 39- <br />A 1 39- f I <br />N I 39- <br />K 1 39- <br />1 39- <br />--Iltlllll11111111111111{{fttllllllllllllllltillllfl{l111llll�Ij.ll�llfflflllltltllllllll{Illtltllllllllllllfllllllllltlllllltllt <br />1 APPROVED k APPROVED WITH CONDITION(S) L S) DISAPPROVED <br />A t ^ aTT WITH CONDITIONS) <br />N 1 PLAN REVIEWERS :LAME `" '•' DATE <br />—Illllltttllllitllfllltlllltttltlltilt11l11ttf1111 Illtl{1 Ilittflt !11{Illlflllllilltlltltilll1l11it11llllllllllt Itlllltlltlll <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 IMALIH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: - CERTIFY THAT ZN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT /S ISSUED, I SHALL 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 />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 />t Director of Special <br />APPLICANT'S SIGNATURE: TUpr-e DAT.. F <br />Gary Nvaren <br />BILLING INFORMATION: <br />Indicate the responsible party to be biped 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 />NameKvarner Arons address11297 Colonia Rd <br />ehone number(916) 631-1646 <br />Signature <br />Gary Nygren <br />EH 23-0038 <br />�1vS 13,G` U• Z. <br />1 <br />