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ENVIRONM&TAL HEALTH DE#ARTMEIJT <br />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 TYPEBELOW: <br />TANK RETROFIT ❑PIPING REPAIR/RFTROFIT ❑i inn RFPAIR/RFfTPr)P1T I Irnl n CTADT/c\/D I IDr DAnC <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # <br />C <br />Facility Name Phone # <br />L <br />Addresses <br />1 <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # acA 7>&L 1111:1 <br />C <br />Contractor Name <br />Phone # <br />NContractor <br />T <br />Address <br />CA Lic # Class <br />R <br />A <br />Insurer <br />Work Comp # <br />TICC <br />Technician's Certification Number <br />Expiration Date <br />Q <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 UST Installed <br />T <br />A <br />N <br />K <br />P <br />❑Approved pproved with conditions ❑Disapproved <br />L <br />A <br />(Se)ttachment With Conditions) <br />N <br />Plan Reviewers Name Date <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: "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 />gg <br />Applicants Signatur Title re�®c0 �lO _ Date c'a <br />BILLING :.•moi► <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 />NAME M®CjaDN ,ta t'a TITLE PHONE # — �-- <br />ADDRESS C�It rr\ C <br />SIGNATUR <br />EH230038 (revised 12/31/07) <br />0 <br />