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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 />f <br />EPA Site # <br />Project Contact & Telephone # <br />C <br />Facility Name kobl Poor-., 4— L iQu-orz. <br />PhonA # I ~X C( — 33'3 — C <br />� <br />Address I �- e- ��o rLNLA E- <br />I T <br />Cross Street <br />Y <br />Owner/Operator 1 <br />Phone #/_4 — 333 - le 3 <br />o <br />Contractor Name ® �" iv rva�}� <br />Phone #` —916 a w 8,6 <br />T <br />Contractor Address 1630 llowslo N <br />CA Lic # 33 JS -9 Class <br />RInsurer <br />A <br />Work Comp # <br />WC 2. 420 112 q <br />C <br />T <br />ICC Technician's Name ` t+ik s <br />Expiration Date <br />p y��� - cl <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 />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />C0 IS-) Q5 <br />A <br />N <br />S 017 <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date l-o% <br />APPLICANT MUST PERFORM ALL 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: 1 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." c <br />Applicant's Signature 12i"Title Dat - <br />— / BILLINY INFORMATION: U <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 />SIGNATURE <br />EH230038 (revised 02/20/09) <br />1 <br />