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SAN JOAQUIN \ CUl \11 <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />C <br />Facility Name Country Club Food & Fuel <br />Phone # 209 662-0952 <br />1 <br />Address 1856 Country Club Blvd Stockton 95204 <br />L <br />TCross <br />Street <br />Y <br />Owner/Operator Phil <br />Phone # 209 662-0952 <br />o <br />Contractor Name APEC <br />Phone # (209) 943-3000 <br />N <br />T <br />Contractor Address PO Box 55105 - Stockton, CA 95205 <br />CA Lic # 341375 Class A / B / C-10 <br />A <br />Insurer State Fund <br />Work Comp # 238-0005332 <br />T <br />ICC Technician's Name Gavin R Williams ( 8016288) <br />Expiration Date 8/6/12 <br />o <br />R <br />ICC Installer's Name N/A <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T <br />A <br />N <br />K <br />❑ with conditions ❑ Disapproved <br />P <br />Approved ,NZRpproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date Oc <br />APPLICANT MUST PERFORM AL WORK 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 <br />TO 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 />,f/ <br />Applicant's Sianature '" ' ^ Title Authorized Agent pie 12/22/10 <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 />ADDRESS <br />APEC TITLE Contractor PHONE # (209) 943-3000 <br />PO Box 55105 - Stockton, CA 95205 <br />SIGNATURE DATE 12/22/10 <br />EH230038 (revised 02/20/09) <br />1 <br />