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A <br />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 />EITANK RETROFIT j4PIPING REPAIR/RETROFIT EIUDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # Ma Z!0711014 7 5 <br />A <br />Facility Name M &04 D,4 Lf Ajk,(.P <br />-t -D <br />11ohone <br />L <br />Address <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator Afic$ 0099 <br />Phone # <br />C <br />0 <br />Contractor Name C— <br />Phone # <br />N <br />T <br />Contractor Address'?' Cwt- A <br />CA tic # t7 Ij qWt Class <br />R <br />A <br />Insurer (AAA <br />Work Comp # 1-7 9,709 Cl <br />C <br />T <br />ICC Technician's Certification Number 5zsqw2 <br />Expiration Date ,T®0 I'D 7 <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date LIST Installed <br />T <br />A <br />N <br />K <br />P <br />DApproved pproved with conditions DDisapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date ")-It r 16-7 <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 AGENTS 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 />Applicants Signature <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 />NAM Zb ?MA _TITLE eD NLa�� PHONE *-1,61' 7-;-Zo <br />ADDRESS 1 C, tL- 50W 0 LA- r <br />SIGNATURE <br />EH230038 (revised P(8/06) <br />1 <br />