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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 />A <br />O <br />Facility Name 4 <br />r- <br />Phone # <br />Address <br />_ <br />TCross <br />Street <br />Y <br />Owner/Operator V1 <br />car Phone # <br />C <br />o <br />Contractor Name �� U <br />�' Phone # 1 `Q " s ,2 Q <br />T <br />Contractor Address` D <br />q 57L0Q <br />CA Lic # 35 i re- Class �4. <br />AInsurer <br />Work Comp # <br />TICC <br />Technician's NameKIS <br />Expiration Date <br />R <br />ICC Installer's Namel <br />,�>� <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />a -- <br />N <br />K <br />t - _-- <br />R 1 !" <br />WAA v <br />P <br />❑ Approved <br />Approved with conditions E, Disapproved <br />L <br />(S A chm nt With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />APPLICANT <br />MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />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 <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature <br />Title 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 acknowledge <br />this responsibility for the billing <br />`by/signature and date below. <br />NAME G e7' ( TITLE �eY PHONE <br />SIGNA <br />EH230038 (revs' ed 07/22/10) <br />2 <br />, f - <br />