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n <br />TRIZ 1 <br />- "ERRim <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 TYPE BELOW. <br />❑TANK RETROFIT PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # 624 ` 4/' q zs zea _ <br />C <br />Facility Name <br />Phone # <br />I <br />Address <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />C <br />0 <br />Contractor Name <br />Phone # —q7 e d l <br />TContractor <br />Address n <br />CA Lic # I Class <br />A <br />Insurer <br />Work Comp # <br />T <br />ICC Technician's Certification Number <br />Expiration Date <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 �Kpproved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />e' <br />Plan Reviewers Name /J Date___41q-/a? <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 CAUFORNIA." 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 />/] <br />Apphearts Sig- (�Gc.X TRIe ® � C40 i_ Date � <br />V 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 />NAME_: <br />AMEC�a f (`�G t tz il't✓tW& TITLE PHONE # ?2,5^ G&) — Z i *F <br />ADDRESS <br />EH230038 (revised 12131/07) <br />1 <br />