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Jun 05 02 02:03p . +20946 42 p.2 <br />ENVIRONMENTAL <br />O1 HEALTH DEPARTMENT P 1 <br />SAN JOAQUIN COUNTY ! . <br />600 East Main Street, Stockton, California 95202 .-- <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERN41T EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />DTANK RETROFIT EPIPING REPAIRiRETROFIT LJUDC REPAIR,'RETROFIT OCOLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # i <br />A <br />C <br />Facility Name <br />Phone # <br />L <br />Address 114"k C- <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator rz t't--, <br />Phone # C r � ' `` <br />C <br />Contractor Name (� 'I t', i'\T `�� /, <br />- 1C. ,� <br />Phone # 2U� fr, f - ' ' j <br />N <br />Contractor Address �_ fir., k'1 't` ' <br />CA Lic # �; ( C 7� • Class i " ) <br />R <br />Au <br />Insurer ,` '' - <br />' •.1 <br />Work Comp#K.•':i :=tea +<;CUC_ <br />T <br />ICC Technician's Certification Number <br />Expiration Date <br />RICC <br />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 />PApproved <br />Approved with conditions DDisapproved <br />L <br />A <br />(S�eb Attachment With Conditions) P <br />N <br />Plan Reviewers Name u� ' �® t� " € �` Date 7 <br />.' 9 <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 />APP 9 t `� ?y _-- Title <br />Applicants Signature � )i i 4 L . 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 r-• for the billing by signature and date below. / { <br />NAME (1 41 � 1 • Ml ' I/ifd` TITI F r:�k ! r�' it lei/?f ::' osann�� it �r�f � tt'`•� "` f ;'.��1 i <br />r_ <br />ADDRESS <br />t� L !! ; 01 ;,-Y <br />SIGNATURE ti; �CU'�(, <br />EH230038 (revised 12131/07) <br />