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Aug.06.2015 10:44 2098871904 2098872639 PAGE. 2/ 2 <br />0 0 <br />ENVIRONMENTAL HEALTH DEPART <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUG 0 6 2o15 <br />iNVI <br />.0jC11R0NMENTA <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW. <br />ri TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIPJRIETROFIT 11 COLD STARTIEVIR UPGRADE <br />F <br />EPA Site # <br />---771 <br />Project Contact & Telephone # <br />A <br />C <br />Facility Nam; )nIrPhone <br /># <br />feo) 926,!q. <br />I <br />L <br />Address AddI <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator N14-il <br />4�1 1 <br />Phone# <br />CContractor <br />0 <br />Name VAJ -1" <br />Phone 0 <br />Phone 1, <br />N <br />T <br />Contractor y <br />Address <br />CALIc# Class <br />R <br />A <br />Insurer <br />Work Comp #tj <br />0 <br />T <br />ICC Technician's Name <br />Expiration Date <br />o <br />iCC Installer's Name <br />Expiration Cote <br />Tank system work area <br />0-9. 87 09no amp, 91 WO ftedor, uDc 112. Mo.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />iI <br />t pj <br />'oe <br />A <br />N <br />K <br />P <br />« Approved <br />Approved with conditions ❑ Disapproved <br />L <br />A <br />A chment With Conditions) <br />N <br />Plan Reviewers Name �Iena <br />Nn,�Io <br />Date <br />APPLICANT MOST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF sm <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 TO <br />WORKER'$ COMPENSATION LAWS OF CALIFORNIA.- <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; "I CERTIFY <br />THAT IN THE PERFORMANCE OFT WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />Of CALIFORNIA." <br />hPI101"'s <br />BILLING INFORMATION: <br />indicate the responsible party to be billed for additional EMD staff time expanded 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 AVIWISS �4 TITLE VY\.C4*'v <br />PHOINEO <br />ADDRESS 00 S I LIArk �1-2-e &- 0- Q -y-l? <br />SIGNATURE;-..... <br />EH230038 (revised 10/30/12) <br />i� <br />