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SAN JOAUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name �^ � <br />5T <br />Phone <br />I <br />Address 39 L4 <br />-BIN/d. <br />T <br />Cross Street v -e- <br />Y <br />Owner/Operator' bb ® I l Jllf - <br />Phone # <br />o <br />Contractor Name yrs <br />®t �� i <br />Phone # C2000BLts — 8-6 8-10 <br />T <br />Contractor Address 1 <br />i` �- A <br />CA Lic # Class <br />A <br />Insurer ZC Envl-ronmei-401'Work <br />Comp # IJ 14 <br />T <br />ICC Technician's Certification Number <br />j 4 S t — <br />Expiration Date9 / O ct <br />RICC <br />Installer's Certification Number <br />54-SaSLA0 <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />Gaso b`n <br />A <br />N <br />K <br />1 <br />14 <br />P <br />❑Approv d <br />pproved with conditions ❑Disapproved <br />L <br />A <br />N <br />L WJIMDate <br />(See Attachment With Conditions) <br />(q - bV <br />Plan Reviewers Na <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 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 />�@L3�LjTitle <br />® a r '+ / / L66 <br />Applicants <br />Signature <br />Date <br />tiILLINU INFUKMAI IUN: <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 />responsibly r g bysi u and date below. <br />r, <br />NAME !( l TITLE xs�PHONE # <br />ADDRESS3 ✓r .h PJI <br />SIGNATURE <6 % tO b <br />EH230038 (revised 8/8/06) <br />1 <br />