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ENVIRONMENTAL HEALTH <br />SAN JOAQUIN COUNTY 11T.;EIVED <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 SEP 2 5 201 <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 />A <br />EPA Site # <br />Project Contact & Telephone #r ��, _c> <br />7346 <br />C <br />Facility Name <br />m3 <br />Phone 14 ? <br />I <br />Address "i7 d _ <br />I <br />TLAD. <br />Cross Street De "t 't <br />r7 -4h <br />Y <br />Owner/Operator <br />Phone # <br />C <br />Q <br />Contractor Name <br />Phone # 1 - - C� <br />N <br />Contractor Address �Jf! <br />CA Lic # Class <br />RA <br />Insurer <br />Work Comp # 2191 - <br />C <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 />Ch i urr <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Installed <br />T <br />A <br />N <br />KLU <br />14 <br />1r,6 HEALIH <br />RA <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS 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: "1 CERTIFY <br />THAT IN THE PERFORMANCE OF THE WO FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's SignatureTitle_ ( �t�� �% Date <br />F2 <br />0 <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, a -g, property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. e�7 <br />NAME _TITLE__ PHONE #��C;3_ (� irk <br />K <br />21 <br />