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111�1 !111 <br />• , A <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 />®TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />D <br />Facility Name }- rri ceps <br />Phone # % r - ri <br />I <br />L <br />Address <br />AddPICr-1 Qj. <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # (-681-6-70S <br />o <br />Contractor Name ,��j ��^ ,�,� j-e(� <br />Phone# <br />N <br />T <br />Contractor Address j - �, / <br />CA Lic # ' Class <br />AInsurer <br />-k--c <br />Work Comp # <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 />Date UST Installed <br />T <br />lCurrently/Previously <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 />Plan Reviewers Name 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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF E 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 COMPENSA I N LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFOR E OF THE K FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA:' <br />he" �� CIVDate ®� , <br />Applicants Signature Title <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for a0itional 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 PHONE #, <br />SIGNATURE <br />EH230038 (revised 8/8/06) <br />1 <br />