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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 ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # A N A <br />C <br />Facility Name b ' M <br />Phone # <br />L <br />Address 33„j L,(j --_. j C,4. 1? <br />T <br />Cross Street cs-t— <br />Y <br />Owner/Operator TS -56 B l CSL J` `r 66 � CO <br />Phone # - 9 & -V00 <br />o <br />Contractor Name %/ i <br />Phone # 07 -696 - S6 2 Z <br />N <br />T <br />Contractor Address ?/- ti°3 <br />, d 01j4L W Q <br />CA Lic # L Class <br />JI 7 5, -4 -Cit} -Uig <br />RA <br />Insurer 1Lfl %f tiU�m% W <br />Work Com # , a 0 <br />TICC <br />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 />P <br />❑Approved approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />c� <br />Plan Reviewers Namek?2l Date *u <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 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 />Applicants Signature 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 />NAME TITLE A6Z PHONE # 21 -2 Y " y <br />ADDRESS'? L(%a A 1,4129 -Ll S h3 0 Al I SO 2- <br />SIGNA <br />EH230038 (revised 12/31/07) <br />1 <br />rA- <br />