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Ll <br />11�111111pii�� 111111 iiiiiiiiii I � 111111 <br />I I� <br />''1 111 iii 11111 I'll � �:Iii 11i � wn <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />7717Project <br />Contact & Telephone # <br />A- <br />C <br />Facility Name <br />Phone #ri4��-I< A <br />L <br />Address <br />T I <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # <br />r Name <br />Contractor <br />Phone # --) -1 <br />Phone err6-il 59 <br />N <br />T <br />Contractor Address <br />&I <br />Class <br />R <br />A <br />Insurer <br />Work Comp # <br />C <br />T <br />ICC Technician's Name A, <br />Z�:Ci;g -3 <br />Expiration Date <br />0Expiration <br />R <br />ICC Installer's Name <br />Date .2 <br />Tank system work a <br />1/2, <br />Tank Size <br />Chemicals Stored Currently <br />Date LIST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC etc.) <br />I <br />T <br />-G -D <br />U <br />A <br />L uL <br />N <br />K <br />,j <br />P <br />❑ Approved <br />J, <br />N_Approved with conditions Disapproved <br />L <br />A <br />--(See Alft*hment With Cond' ions) <br />t o62 -e <br />N <br />�Plan Reviewers Name. <br />Da e <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 <br />To WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S <br />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFOR�MA=NW5<7F7 EW7FrORIC THIS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />rApplicant's Signatuog� <br />Ti41en2D g2C'—jt-Z - - at-- �(-02- <br />X <br />:114 4 1 Z rel I "q I <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 />NAMEOCr -U7VLA _TITLE 0 HONE #4609 R3e1�00� <br />EH230038 (revised 07/22110) <br />2 <br />