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;s yI <br />BILLING INFORMATION <br />r,.11_;pte the responsible party to be milled fur additional EHD staff time expended beyond permit payment coverage per tank. If <br />°fte part; designated below is different than the permit applicant, e -g.; property owner, the party must acknowledge this <br />resr-onsibiltty for Inc bitimo by'signatufe and date below. <br />—TITLE n6 E!aaA t C ek.,PHONE # 209-339-2371 <br />255 E Harnev Lane. Lodi p <br />DATE <br />F <br />EPA Site # Project Contact& Telephone # Emi(y Grain 916-371-2380 <br />A <br />Facility game Hartley Lane Arco <br />Phone #209-339-2371 <br />Address 255 E Harney Lane, Lodi <br />L <br />_ <br />Cross Street S Stockton St <br />Owner/Operator11 - - - - _ <br />-- Phone # <br />'Contractor Name BZ Maintenance <br />Phone #916-371-2380 <br />1 <br />N <br />Contractor Address PO Box 933, W Sacramento, 95691 <br />CA Llc # see attached ` class <br />T <br />insurer See attached <br />work comp # <br />A <br />T <br />ICC Technician's Name see attached <br />Expiration Date <br />o <br />ICC Installer's Name <br />Expiration Date <br />R <br />Date U5T <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />installed <br />(: a 37opin9 s.m5p, 9' Ink peieoor. UDC i2, et_ ) <br />87 drop tube ; X 2 <br />24431 <br />87 <br />A <br />91 drop tube <br />12904 <br />91 <br />K <br />DSL drop tube <br />DSL <br />Approved Approved <br />with conditions Disapproved <br />P <br />_ <br />L <br />ee/Attachment With Conditions) <br />� <br />N <br />Plan Reviewers Name <br />tl"y 1 <br />Date "'=`I hy <br />APPLICANT MUST` PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />"I <br />COUNTY: ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:. CERTIFY THAT IN <br />TO <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 />"I <br />p['wORKFP'S COMPENSATIONLAWS OF CALIFORNIR CONTRACTOR'S HIRING OR <br />SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. CERTIFY <br />TO WORKER'S COMPENSATION LAWS <br />#THAT IC! <br />THE PERFORkWXI E OF THE WORK, FOR WHICH THIS PERMIT IS ISSUED, I <br />SHALL EMPLOY PERSONS SUBJECT <br />OF CALIFORNVA <br />+� <br />�. <br />ADol�G9[if. <br />Stcgatu([�. � Till e' <br />Dale <br />1 <br />