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SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />111 ill 1 11, a i I <br />r::.. <br />,1:* 9.1101.1111 11LO-1:4:1 W I &p2:4:4g'r:: <br />_ clqv <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW <br />❑ TANK RETROFIT 0 PIPING REPAIR/RETROFIT 11 UDC REPAIRIRETROFIT 11 COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name Phone# <br />Address <br />LT <br />Cross Street <br />Y <br />Owner/Operator Phone # <br />C <br />Contractor Name p Phone # 1 - 2„"T -'l 1- <br />0 <br />N <br />T <br />Contractor Address j�c (-,12- LID # 113 classben ft/ 62k <br />R <br />A <br />Insurer Work Comp # <br />C <br />T <br />ICC Technician's NameExpiration Date <br />0 <br />ICC Installer's Name 1�-4 A Expiration Date <br />_R <br />Tank system work areaTank Size <br />Chemicals Stored Currently <br />Date LIST <br />It e, 87 piping sump, 91 leak aetector. UDC 112, etc) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />Approved Approved with conditions Disapproved <br />I L <br />(See Attachment With Conditions) <br />A <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 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 WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />"a 1 <br />jApplicant's Si nature Tithe <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 by signature and date below. <br />NAME TITLE PHONE# rto <br />L <br />ADDRESS <br />SIGNATURE DATE <br />EH230038 (revised 07-17-2014) <br />R FIN <br />". <br />2 <br />