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[ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />=1Z1(*1 2 1&$] AU 1:111 Hes Z442-3 1 Z41 UA V11, <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT o UDC REPAIRIRETROFIT o COLD STARTIEVR UPGRADE <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 />EH230038 (revised 07-17-2014) <br />TITLE PHONE# <br />N <br />1111RIMM <br />IS, <br />DEPARTMENT <br />I <br />IT - &Iq "641111111111 <br />C <br />0 <br />N <br />T <br />R <br />A <br />41 11114 <br />WW AW <br />C <br />T <br />0 <br />R <br />Expiration Date 0 <br />ChemLls Stored Currently <br />Date LIST <br />Installed <br />�Ikx <br />a <br />11 Approved <br />D Approved with conditions Disapproved <br />(See Attachment With Conditions) <br />Plan Reviewers Name <br />Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />0 A N — '�'9 L�,-NTAL HEALTH DEPARTMENT. <br />QU' CO"4 <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THEPFRF,"!.'- ,K FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />- <br />WORK CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT I <br />";�THOF <br />E WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CO' <br />�—V! <br />Ap Z <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 />EH230038 (revised 07-17-2014) <br />TITLE PHONE# <br />N <br />1111RIMM <br />IS, <br />DEPARTMENT <br />I <br />