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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 # (-A% <o) Case, - `®g o <br />A <br />O <br />Facility Name D - i'. -r -N .,`7 r -t+ Phone #Cl\e-) $S$ -1105 0 <br />I <br />Address <br />I <br />T <br />Cross Street E • �,,� „�,`�„� Q �,�,,.Ce-__ <br />Y <br />Owner/Operato eA ,' T- <br />Phone # g`v 858 -LOG'o <br />C <br />O <br />Contractor Namg�. <br />- ® • .'k' w w1 w v% e • ve t- <br />Phone # �at \ l0 i t o 4 O <br />N <br />T <br />Contractor Address CA Lic # Class A'a, , 0 -to, A g <br />i ♦%$ 'Tara �r lv � $ 4�$ OQI <br />RInsurer <br />A <br />�,o�� <br />�'cv,Dt„1.,�.R.3 _ t^'' � CoSIU'e\ C 0mj?onV Work Come # VB-•7ZNL1 @7 03 <br />T <br />ICC Technician's Name .r. Expiration Date q 3 o t l <br />D <br />ICC Installer's Name • t,'y <br />Expiration Date <br />P i 0 O �-i <br />12— <br />Tank <br />Tank system work area 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 />°oo ® <br />a E 3 G t.. <br />`` <br />Js+.N K1�13 <br />A <br />N <br />K <br />P <br />proved pproved with conditions ❑ Disapproved <br />L <br />lith Conditions)A <br />N <br />I(SeeAttachment <br />(� <br />Plan Reviewers 1 / Z ��� V <br />Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY DINANCES, 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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature_, _ Q na�t.- Title w ate <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 by signature and date below. <br />NAME(1i�se,�nC••e.� Sc�.ceno�_ TITLE-IC'.oeec-A el®d PHONE #�a`ta) 1BSb-t00(0 <br />ADDRESS ♦A�$O �'r®.cS.o_� C��"ta�. �2aa1� e^c4►opv�oy/� aSi`IZ. <br />SIGNATURE �� �`� _� .� e� DATE t k — lw ^-'® O <br />EH230038 (revised 07/22/10) <br />i "At <br />