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S A N 1 U A Q U I N Eoviromnantal Health Uoparlmont <br /> < ( ' ) UN1' Y <br /> APPLICATION MR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> Tllitl QE111AfT I XTyHI ' !; Ina DOV:. I fi0M TOIL APPI10VAI. WE "0CATIV F1 KW f V" *Ll0W <br /> I I TANK RETROFIT M PIPING REPAIRIRETROFIT t) UDC REPAIRMETROW u COLD STARTIEVR UPGRADE <br /> I i: 1'A seta H Prat CarAW A T� >>r t k PPobleno. (200) t1 2101 <br /> A �7:4 - <br /> V uci►ity Nal"a Va Pacific Pattolourn Fresno Ave Cardock - <br /> t Address 1524 Frenso Avo, Stockton , CA <br /> �rr <br /> Cans arrest Charter Way <br /> Y Owner/oporstot . valby Padllc Potraloum Servio" Pho11'e M 204) 9" '12 <br /> 0Coltraetar Name CARS _ Pts N (In 62745316 _ <br /> E � <br /> N Contrnictor Address 5944 Dry CIT A Rd, t> wwnWo, CA 055 CA Ue f SMS Cies A HAZ <br /> RA Insurer Zurloh American Inswarow Ca Mt<rk Cana M WC <br /> !GC teattnlclsrl's N the Josh Simmons ExpMon Dole 9/30/2022 <br /> T - - <br /> U ICC Instalttlr's Nwe Josh Simmons ! iroUarl (aata 1 /15!2022 <br /> R - - <br /> Tank sysMam work atom Tank Sim Chanftsils Stored C,arordly trete UST <br /> 0 a Sir pog Aft it 1&* awn, U00 Wo WL) Inlet" <br /> T fl?QrMlhiriltl - - - aaapo � <br /> A - - <br /> 1 — - - <br /> n <br /> I ' LJ ApPrpvod I I Apprav+ d vA4h earl de+ls � - I Dim <br /> t. (See Atta& nen ttI Condiitans) <br /> A <br /> N Plan RavieworaNarno - D <br /> I IcANT MUaT Pmr(*M ALt. WORK 1N ACCOWW4cE wTH a. 40AOLNN COIRRY c POWM & 5TATZ LAYW AND RUUES A"D REGULA11" OF 80 <br /> DAQUIN COUNTY VN5/11tONMt;NTAL HEA111i 6EFAlITMENT, CMhIER QR LkYNSED AfkJrrY Z310MAIUa1tS (�ATirT£$ TFi� FOt1OW11Mi_ '1 CERTOFY THAT Ml <br /> HE IVIA AMA►f4-C UT Tte WORK FON WwAi TWO NEAW1 Ib la6UL'• C, I S"t NOT CA PLOY ANY PFRBCMi W 8WH A MANKLN AS TO a§CCS all ACT Ta <br /> V�MoKllhla 00WENUT10N LAWS OF . C"GRMA' CONTIMTon MIk1NU CR 41,11aC4NT0410d SKWATM Celllwws US PoLLAVYINCF 1 C@111tfY <br /> THAT IN THG PrPY ftMAW or *9 WORK FOR WteCH 7I40 PEHMI I IS I& ilEi), I NMI f:IAF'tUY KRWNS WWCT TO 1h MUWS CoWf" SA7M LA%W <br /> F MIFO <br /> oo Gorn Wercial Fuelin Mane r 1 /2112021 <br /> 81MING INFORMATION. <br /> Indlcota Oto rosponalble party to bo billod tar add4tlonal EHD staff limo expended beyond pwmlt Payment cevenvo Po <br /> trink. If tho party designstod bataW Is difloranl than the Parm11 applicant. o-g, Property &ernes, the paty must <br /> acknowledge this rasponsiblkty tat the b411utg by Wonature and dab glow, <br /> NAME . mow E1lsson Co mart,IrA FuekV Manner Ptii)NE R 112" 00"743 <br /> AWAEsB 162 Frank Waal Ord@, Sloaktoo CA OW <br /> siaNA rt* - MTF- 112112021 -- <br /> Sao <br />