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304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT PSUDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name fV 1C-9'9 515& LC_ <br />Phone # �-o9 - ,4o3 - 385 jl <br />L <br />Address 5-ia C) 4PrP 25- 3 <br />1Cross <br />T <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />C <br />oC <br />Contractor Name /U /� N fi�C' = <br />Phone # <br />N <br />Contractor Address-pb--ibo x a9 (Ilkbovr G+ 17 <br />CA Lic # 7( Y9 5 E Class <br />A <br />Insurer P r <br />Work Comp # C�Ie4` <br />C <br />r <br />ICC Technician's Certification Number q,4 / p <br />Expiration Date /- /y'_ 0)0l <br />O <br />R <br />ICC Installer's Certification Number -4 314%0 /49(/' <br />Expiration Date 1 - 11 - ar) / 37 <br />Tank ID # <br />Tank Size <br />Chemicals Stored Date UST Installed <br />Currently/Previously <br />T <br />A <br />N <br />K <br />P <br />❑Approved Approved with conditions []Disapproved <br />L <br />(See'Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name ,� .� �` ��s`Z �. Date 2, <br />APPLICANT MUST PERFORM ALL 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 TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 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 />�® <br />> <br />Applicants Signature)2 TiUe 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. C <br />NAME AhGIL- Y50 f TITLE � PHONE# <br />ADDRESS 1 (O ct Z) ! / 1�4, 4 9-S-322) <br />EH230038 (revised 8/8/06) <br />1 <br />