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EVVIRONANTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />OTANK RETROFIT OPIPING REPAIR/RETROFIT 11UDC REPAIR/REIROFIT <br />F <br />EPA Site # _TProject <br />Contact & Telephone # _3QLq10376?a663 <br />A <br />C <br />Facility Name Ph one# <br />'VInno <br />I <br />L <br />Address toFvir- <br />A. <br />T I <br />Cross Street <br />Y <br />Owner/Operator 5a <br />Phone # 1/6 -9DZ? - 15'7 2 (e <br />C <br />0 <br />Name ame -IT WAVA eA.L M t:�\j lc& <br />Phone1 <br /># 7(o <br />N <br />T <br />Contractor Address Ly\ W.'�,ACJD <br />ICALic# (7,j(,f-jj_1t Class <br />f� - <br />R <br />A <br />eD <br />, Insurer WC, R)LYX4 <br />Work Comp # <br />C <br />T <br />ICC Technician's Certification Number <br />Expiration Date <br />0 <br />R <br />ICC Installers Certification Number -6-2,15D)bte —LA <br />Expiration Date al / S Lon <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date LIST Installed <br />C <br />T <br />A <br />C <br />ujIbAe- <br />N <br />K <br />P <br />DApproved %pproved With conditions ElDisapproved <br />L(See <br />Attachment With Conditions) <br />A <br />N <br />0\_k�OJ�6 <br />Plan Reviewers Name, R!�4 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 TO <br />WORKERS 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 />Applicards SwIlf 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 />SIGNATURE <br />EH230038 (revised 8/8/06) <br />TITLE —PHONE *. <br />1 <br />