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L <br />.1171111 1 1 'A I <br />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 />� <br />Facility Name ! <br />Phone # 07 — —9 1 <br />1 <br />L <br />z <br />Address .� , ko C -4: - <br />Cross Street 1 <br />Cross <br />Y <br />Owner/Operator t a <br />Phone # _ 4-14- tZ <br />C <br />Contractor Name ; <br />Phone # <br />N <br />T <br />Contractor Address <br />CA Lic # Class <br />RInsurer <br />A <br />Work Comp # <br />Q <br />T <br />ICC Technician's Name <br />Expiration Date <br />Q <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T <br />� � �1 <br />0- 000 IA- <br />t <br />�. <br />A <br />�G <br />Z <br />N <br />K <br />P <br />❑ Approved pproved with conditions ElDisapproved <br />Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Na J Date®>I <br />APPLICANT MUST PERFORM 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: "I CERTIFY <br />THAT IN THE PERFORMANCE OF TH WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />i <br />Applicant's Signature=4=,,/ ,I'21J0Z1,-- Title Date <br />11 " l BILLING INFURMA I IUN: <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 ,A��'�`c� C� <'.�r-, TITLE � C -r c"�� PHONE# 2-007— L�-T�I <br />®1�-�jIZ' <br />ADDRESS <br />SIGNA <br />EH230038 (revised <br />2 <br />TE ZZZIf <br />