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JOAQUIN0 10 <br />ENVIRONMENTAL HEALTH <br />SAN i , <br />1868 E. Hazelton Ave., Stockton, California 95205 FEB 0 6 2017 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />6 TANK RETROFIT PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # fj 7((® <br />A <br />C <br />Facility Name <br />Phone # <br />I <br />L <br />Address /-7 -7 t <br />T <br />Cross StreetUA It Q, r <br />Y <br />Owner/Operator <br />Phone # <br />oContractor <br />Name <br />Phone 2 S <br />TContractor <br />Address <br />CA Lic # ;-o e Class &,4, C <br />A <br />Insurer ° 'lam <br />Work Comp # =A ® f. <br />TICC <br />Technician's Name �, <br />Expiration Date „/ <br />RICC <br />Installer's Name �L4q ` � � <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />A <br />N <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 <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 TO <br />WORKER'S COMPENSATION OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PE OR K FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Title OCC Date & l % <br />BILLING INFORMATION: <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 1 _�' TITLE J1 C -e PHONE #?75--2-10 —25'-29 <br />EH230038 (revised 7-26-2016) 2 <br />W <br />