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.111 111��11111111 i <br />III ,7; i i <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fag: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTtEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # 9/y • %s <br />� <br />Facility Name ,-3 <br />Phone # <br />L <br />Address <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />cContractor <br />0 <br />Name J'P ®- <br />Phone # p®� . <br />T <br />Contractor Address A Lic # 7G8' Class ..jotow <br />A <br />Insurer ® ®B,nJ VC <br />Work Comp #G' <br />T <br />ICC Technician's Name <br />Expiration Date r <br />o <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area Tank Size <br />(i.e. 87 piping sump, 91 leak detector, UDC M, etc.) <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />01-7 r2 IA21e— <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date l6 <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, 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: "1 CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Title &W74AW4 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 b signature and date below. G�♦ <br />NAME TITLE PHONE # <br />ADDRESS c aow% <br />95-763 <br />SIGNATURE ® DATE 1 2�/%41 <br />EH230038 (revised 02/20/09) <br />1 <br />