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C <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name i a ml b 74,Phone <br /># 2,01-932 -/307 <br />1 <br />Address ee un f7^ C/Gi% 111 '. S �C� <br />o�J�%� <br />1 <br />T <br />Cross Street jo( Yri0a-kYi <br />Y <br />Owner/Operator ea I t A� e <br />Phone # <br />o <br />Contractor Name ��� 7L1�!>%EGA <br />Phone # <br />N <br />T <br />Contractor Address ���,rSaO �� <br />�i. <br />CA Lic # / G +� Class Cfo / �b <br />A <br />Insurer �i��e % 17d <br />Work Comp #90 �y y 33 —ZO J <br />T <br />ICC Technician's Name GExiration <br />p Date v U i© <br />R <br />// <br />ICC Installer's Name G> f ' � 6 e-/ <br />Expiration Date 'C) % 11-7h f j f <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved pproved with conditions ❑ Disapproved <br />L9 <br />} (S .Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name ' Date <br />APPLICANT MUST PERFORM ALL WO 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 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />^ A l ^-AX�/��� � <br />Applicant's Signature �` Title Date <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME lil�611I'` Ileen?.cO TITLE / �€/ PHONE# <br />ADDRESS `'7� G�yolf'l QS�'YJ t C1�t 9 I - <br />SIGNATU <br />EH230038 (revised 10/30/12) <br />2 <br />0/hs-/// <br />