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C� <br />•1 111 11 IN IN <br />� i � 111211111 11. <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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />FacilityName <br />ariV 1Phone <br /># 9/0-371-1,5-7b <br />� <br />Address lKqa S. [ <br />!Z <br />TCross <br />Street <br />Y <br />Owner/Operator CcLm, <br />Phone /( -3 7/ —257 o <br />o <br />Contractor Name <br />( <br />v ! <br />Phone # �j / (a -a — 3 <br />N <br />T <br />Contractor Address <br />A Yl <br />CA Lic # j j ( Class (�� C, <br />R <br />A <br />Insurer <br />Work Comp # <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />vllfl <br />j' <br />Expiration Date f <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />jC <br />Uri ? <br />A <br />N <br />K <br />P <br />❑ Approved <br />Vproved with conditions ❑ Disapproved <br />L <br />(SeXachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />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 <br />PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN <br />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 Signa <br />Title ® Date <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; .ly <br />- TITLE PHONE # q16 Q `S� <br />SIGNA <br />08/1/11) <br />E <br />