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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECEIVEJ <br />600 East Main Street, Stockton, California 95202 APR 11 2011 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />9 :1912 1 IM :41 U I U 10 P" :4 =91:1il I M41 U =1 <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 />A <br />C <br />Facility Name APIE0 <br />Phone L <br />L <br />Address m lei <br />T <br />Cross Street Utt <br />Y <br />Owner/Operator RIa. 6vS_,5;e4�-Phone <br /># x <br />C <br />Contractor Name r (�51f <br />Phone #71Y 31 of- 374 2 <br />T <br />Contractor AddressCA <br />Lic # 7,9 G4�Q Q, Class G�- <br />A <br />Insurer $. <br />Work Comp # 83 1112 1-5-3 <br />TICC <br />Technician's Name j®® (,e T- <br />Expiration Date <br />R <br />ICC Installer's Namee f�®. Gr T- <br />Expiration Date ac� <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T <br />f/% <br />,9 <br />rd PrelveLt <br />A <br />�Gn v O d ► =. <br />N <br />K <br />P <br />❑ Approved pproved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Nam %� Date <br />APPLICANT MUST PERFORM 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 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />ry <br />Applicant's SignatureTitle Date <br />BILLING IN ORMATION: <br />Indicate t responsiblep y 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 acknowledge <br />this responsibility for the billing by signature and date below. <br />NAME Fa -S G TITLE PHONE # �V-31'7-37,1j <br />Pa <br />