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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209) 468 - 3420 Fax : (209) 468 -3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 160 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE OE CA& <br /> rt TANK RETROFIT O PIPING REPAIRtRETROFIT ❑ UDC REPAIR/RETROFIT U COLD STARTtEVR UPGRADE <br /> F EPA Site t1 — --1 ProJact Contact & Telephone it -� ^_-- <br /> A <br /> Facility Name Kwik Sery Lodi --- _ 'Phone tt209- 577- 6000 <br /> t Address420 W Ketitlernan Lane , Lodi _ <br /> I Cross Street <br /> Y OwneriOperator B&W - Scott Castle (VP) Phone it <br /> c Contractor Name BZ Maintenance Phone is 916-371 -2380 <br /> N Contractor Address PO Box 933 , W Sac , CA 95605 CA Licit Class <br /> A insurerSee`attached Work Comp ft <br /> G JCC Technicians Name <br /> T ' see attached Expiration Date <br /> oIGC installer's Name Expiration Date <br /> Tank system viork area Tank Size Chemicals Stored Currently Date UST— <br /> � e7Fc_�; a_ r , atl . Lrsc1Recy Instal'ed <br /> i 87 drop tube 10000 infing87 <br /> A 91 drop tube 6000 �� 91 <br /> N <br /> K DSL drop tube 8000 ,r DSL <br /> E 85 drop tube 7000 '889— E85 -- --- <br /> F, i i Approved Approved vrlth conditions i i Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> rt Plan Reviewers Name Date <br /> APPi WANT 140ST PERFORPA ALL.. WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAW, AND RUI. E5 AND REGULAIiONS Of SW4 <br /> faQUIN COUN11Y Et4MRONVU TAI. HEALTH 0EPARTIALNT . OLVNER OR LICENSED AGENT'S SIGNATURE CERTIFIES 1HF FOLLO +S' WI `i GER10 Y THAT IN <br /> [IV: Gr NF(iF 1-�ANC" E Or THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A VARNER AS TO 6ECC"It,TE SUErJECT TO <br /> ;WMFXRS COMPENEAT EON LAWS OF CALX-ORNIA." CONTRACTOR'S HIRING OR SVDCCNTRACTING SIGNATURE CERTIFIES Ttir. FOLLOWING `i CERT €=Y <br /> THAT PT THE PFRFORLka,NCF OF THE V' ORK FOR Wti=_Cti 1 HIS PERMIT Is Issurc) I SHALL EfdPLOY PERSONS SUBJECT TO WORKER'S COMPENSAT➢UN [AWaS <br /> Or L/ LIrOM4A <br /> srn= A a v .� r Titio I tU Date C� -, ��4 } . <br /> BILLING INFORMATION <br /> IrrtscMe ihst mzjeonsiblo party to bo billed for additional END staff time expended beyond permit payment covorage pnr tank If <br /> the; party WksfUnatcd beltwr Is different than the permit applicant, o-g property ovincr , the party nutst eckatAvedge this <br /> rc porisibi ny for the tMhng by signature and date below <br /> re rr e Monica Farhat Operation s/Complaince 209-577 -6000 <br /> —_-- _ _-- ._THI- FPI IONC P <br /> AT`9.)R I_"s'3 601 McHenry Ave , Modesto <br /> C7A1 f_ ' --- <br /> u3GrdAT UFtE <br /> "12,M03n (mmsed 12- 1 1 ib) 2 <br />