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Environmental Health Department <br />• • •- r at 1k - -• N W- I <br />THIS PERMIT EXPIRES 18D DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact <br />&Telephone # ylt:L l y — <br />Facility Name <br />Phone #21L6152 '0512 <br />L <br />Address`liooLy'iE.' <br />_ 1 _ �24 <br />Cross Street <br />Y <br />Owner/Operator Q h <br />Phone # <br />oContractor <br />Name <br />Phone # <br />_ + <br />N <br />T <br />Contractor Address <br />CA Lic # �� Class Pk AID AAA <br />AInsurer <br />U <br />Work Comp # <br />T <br />ICC Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />p,e, 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />- <br />,� <br />_ <br />P <br />(Approved with conditions <br />El Disapproved <br />L <br />(See chment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date Z 1Ziv <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS <br />SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />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 T IE WORK FOR WHIG THIS PER S ISSUED,KNEMPLOY <br />OF CALIFORNIA." <br />L PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />Applicant's SignatureTitle — <br />{ Date <br />BILLING INFORMATION: <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 <br />acknowled�g/�e this respo�n/s}i�b��i�li for�(th'�e'}bill'`i"n�g by si ture a d de <br />NAME ` ST ° A I 1 (ij f TITL%E �Y� � I�1 � PHONE <br />ADDRESS La 11) i6w !T \. V .1V� . c lA Y) b;9 . t A <br />SIGNA <br />3of6 <br /># ��� -213--- too <br />ATE <br />