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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 REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name C� <br />Phone # c C(q I <br />1 <br />Address ,�� �v r` CN q, �� I <br />T <br />Cross Street C,0k& <br />Y <br />Owner/Operator �,` ® `; ; �, <br />Phone # ti' (0 3 (� <br />C <br />0 <br />Contractor Name w— 0 t <br />Phone # c, al 1, _ 2�3 <br />T <br />Contractor Address q(a 7D <br />CA Lic # V') -a-34 Class k?) WA Z C&1 <br />A <br />- <br />Insurer all�� S <br />Work Comp # 0 23 <br />)015 -D) -305- <br />C <br />T <br />ICC Technician's Name �, r <br />Expiration Date ,® t <br />R <br />ICC Installer's Name ro <br />Expiration Date L, <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />g-7 F. I1 <br />A <br />N <br />K <br />P <br />❑ Approved pproved with conditions ❑ Disapproved <br />L <br />(Se,p4pachment With Conditions) <br />N <br />Plan Reviewers Name i Date `vim <br />/ ::��jA it 2— <br />APPLICANT MUST PERFORM ALL WORK 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 SH LL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." 5 <br />L-�Title �,y <br />" ✓ ' Date .� <br />Applicant's Signature <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 e / PHONE # L 1)X'% I -'3.3 0 <br />.. t- ..I I r J N /,-A r, <br />SIGNATU <br />EH230038 (revised 08/1/11) <br />2 <br />TE J/Is-/-/ <br />0 <br />