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SAN JOAQUIN COUNTY <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 IXPIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Veronica 916-373-1167 <br />A <br />C <br />Facility Name CRLLC #2705446 <br />Phone # 209-943-2082 <br />I <br />L <br />Address 1403 Country Club Blvd. <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator <br />Phone # <br />C <br />Contractor Name <br />Phone # 916-373-1167 <br />T <br />Contractor Address <br />CA Lic # 6172 3 8 Class <br />A <br />Insurer BE Insurance Corp. <br />Work Comp# QWC4000674 <br />T <br />ICC Technician's Name see. attached <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC v2, etc.) <br />Installed <br />T <br />isp. #1-2 Dsl Shear Valve <br />ge_no <br />Chan e <br />A <br />N <br />K <br />P <br />❑ Approved <br />pproved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />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. <br />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 <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature <br />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 />NAMEWal t-c)n Fngi nPPr_j nq, Tnc- _ TITLE PHONE# A16-373-1167 <br />ADDRESS <br />SIG <br />EH230038 (revised 08/1/11) <br />'r.' <br />61 <br />