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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazeltorl Ave., Stockton, California 95205. <br /> Telephone; (26�) 468-3426 Fax: (209) 468-3433 <br /> APPLICATION F04 UNDERGROUND STORAGE TANK <br /> RETROFIT ()R PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS NROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT .0 PIPING REPAIRIRETRQFIT ❑ UDC REPAIR/RETROFIT O COLD START/EVR UPGRADE, <br /> EPA Site# Project Contact & Telephone # <br /> C Facility Name George Kishida phone# 916-368-0603 <br /> lt. Address 1725 Ackerman Dr, Lodi 95240 <br /> I Cross street <br /> -- - -- - I <br /> Owner/Operatnr�,/ G Phone # <br /> Q W Contractor Name_ SZ Maintenance Phone # 916-371-2380 <br /> T Contractor Address PCB BOX 933, W San 9OP91 I CA Lick A,33159 Class A B C-61 D40 <br /> 7 <br /> a Insurer see attached ; Work Comp # <br /> T [CC Technician's Name see attached i - Expiration Date <br /> R ICC Installer's Natne Expiration Date <br /> Tank system work area �7ank Size Chemicals Stored Currently <br /> Date UST <br /> tt o,rot Nptr,g sump. N leak onteant.'JOC 10.etc,) Installed <br /> T <br /> DSL 1 S1'P <br /> A �( <br /> IN <br /> h, <br /> P i Approved ;Approved with conditions t. Disapproved- - <br /> L- (SIte Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name- �btrlr o f __ Date. al- a�� Z01 <br /> t <br /> APPLICANT MUST PERFORM ALL INFORK IN ACCORDANCE WITH SAN JOAQUIN' COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL. HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 18$UED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA!' CONTRACTbR'S HIRING OR SUBCONTRACTING SIGNATURE' CERTIFIES THE FOLLOWING "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERrIT IS ISSUED, I SHALL EMP40Y PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." , <br /> Margar'et Smith Compliance Testing Coordinator 2/3/2026 <br /> Aj)OIcant's Sigr eture _. _ T(ue gate <br /> BILLING INPORIVIATIM <br /> t <br /> Indicate the responsible party to be billed for additional PHD staff time expended beyond permit payment coverage per tank, If <br /> the party designated below is different than the pen; it applicant, e,g, property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below, <br /> NAME.Georoe.Kishida �_ _TITLE PHONE # <br /> i <br /> X <br /> ADDRESS 1725 Ackerman Dr, Lodi 95240GNATU j DATE <br /> EH230038 (revised 12-1145) 2 g <br />