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ENVIRONMENTAL HEALTH <br />TSAN JOAQUIN COUNTY c. 1= 41 <br />304 East Weber Avenue, Third Floor, Stockton, California 95 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433,$ L <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 600 OCC ��� (i (c, Phone # 73- i 3 3 7 <br />S <br />L <br />Address 2 7®/ a-,j� S j <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />C <br />Contractor Name � (,74U <br />Phone # <br />NContractor <br />T <br />Address °`l � �. , c�- r,C.-i C-6� <br />CA Lic # a Class <br />AInsurer <br />ri�64t-1 <br />Work Comp# 51/2 3c/0-7 <br />C <br />T <br />ICC Technician's Certification Number � Ot.4 d �Ga-�O�-� <br />Expiration Date Z- 0 1 <br />p 3 . <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <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 Name 10 Date 51 4101 <br />APPLICANT MUST PERFORM ALL WORK IN ACCO DANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS 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 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />7 r f— t �? <br />ate l [ ` '7— U <br />Applicants Signature t ,Xjl n�� ¢iP Title q 0 f � D 2 <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 PHONE # <br />ADDRESS <br />SIGNATURE <br />EH230038 (revised 8/8/06) <br />1 <br />