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ENVIRONMENTAL HEALTH <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 REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />G <br />Facility Name Vpteezo �� S'To * 3 ,!-( <br />Phone # ��� - ®`3 r o ) <br />I <br />L <br />Address Ci ' P� � iL � � � 5' T 0CV--i L <br />T <br />Cross Street fN i QA. lit <br />Y <br />Owner/Operator \/J\ i- 0- L-14:702-" if,. ej�t® "A! L (�{3 <br />Phone # <br />CContractor <br />o <br />Name - — t <br />I�tLL l��►�I cNai�\C� <br />Phone # , " =' <br />`�`s`� <br />T <br />Contractor Address Cc pb�i N ` V- I) t - C <br />CA Lic # Class <br />AInsurer <br />Work Comp # <br />TICC <br />Technician's Name e ®c. <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />A <br />CS4De Attachment With Conditions) <br />�7 <br />N <br />)�^ <br />Plan Reviewers Name Date ( / &//%/ <br />APPLICANT MUST PERFORM ALL VZRK 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 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 />�—" %jGB Cr <br />��u � /' � <br />Applicant's Signature Title 1. Date <br />BILLING INFORMATION: <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. fit_ <br />NAME °"-d�`� 4Q;--5= TITLE `—�F���tiAVl� 1.��'�G PHONE# <br />ADDRESS �0 41 P -Cl S'1 Y �Z � � i� �i� �� �' iS . 01 k:� q� � �a <br />SIGNATURE G� _.d DATE, t` <br />EH230038 (revised 07/22/10) <br />