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A <br />I L , <br />Nez I = k W; *� %1; j ffij I "W 4 4W"i 1; 0: a; 4 Z4 R, <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name —T— <br />Phone # <br />L I <br />Address f <br />I <br />C t St <br />ross Street 4ArW <br />Y <br />Owner/Operator <br />Phone # 2-iU, ' 7 <br />0 C <br />Contractor Name <br />Phone # <br />N <br />T <br />Contractor Address AWKkR-- A V(f <br />CA Lic # Class <br />R <br />A <br />Insurer l t I <br />Work Comp # –;RSOP64e <br />49 <br />C <br />T <br />ICC Technician's Name 10A ArQ <br />Expiration Date 61 /0 /:;?-Cl <br />0 <br />R <br />ICC Installer's Name 1") Is -,I <br />Expiration Date t 4 'Df' <br />Tank system work area <br />(i.e. 87 piping sump, 91 reek detector, UDC 1/2, etc.) <br />Tank Size Chemicals Stored Currently <br />Date LIST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved Disapproved <br />L <br />A"Approvedw�iftth�cwondft!ions <br />N <br />Plan Reviewers Name Date <br />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 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 <br />To 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 />Applicants Signature Title Date <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />NAME TITLE 6VI t4"3-0` t--c--PHONE #—C172!---';� <br />� &>-7c —2 <br />SIGNA <br />EH230038 (revised 07/22/10) <br />��fflffl� <br />�A'#]�"A <br />im <br />