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ENVIRONMENTAL HEALTH DEPARTMENT <br />111 11 11 IN <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # u:u It° I > ®tet <br />C <br />' <br />Facility Name k <br />Phone <br />L <br />Address rin <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />cContractor <br />0 <br />Name �, , � �q <br />Phone q _q7 _ 01 <br />T <br />Contractor Address �, `� n AV— <br />CA Lic # laof Class <br />RInsurer <br />Work Comp # <br />TICC <br />Technician's Certification Number j'� ®- :i— <br />Expiration Date <br />o <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored Date UST Installed <br />Currently/Previously <br />T <br />A <br />N <br />K <br />ElApproved FXpproved EDisapproved <br />P <br />with conditions <br />L <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name &t tk�,Z- n Date 14 -PT <br />IF r <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: N 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: "1 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." , ( J --ry <br />!d <br />ApplicantsSignatu !2C,Ii S Title O 7 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 />NAME t I (`�� TITLE PHONE # (725– 2a) - 9? <br />SIGNA <br />25– <br />SIGNA <br />EH230038 (revised 12/31/07) <br />1 <br />