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0 9 a 'k :411 ivi I gm <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />LITANK RETROFIT ❑PIPING REPAIR/RFTPOP1T F , , — <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # <br />C <br />Facility Name 1 M Phone #2643 <br />� <br />Address 26D1 E. <br />TCross <br />Street <br />Y <br />Owner/Operator 80qM <br />hone # <br />0 <br />Contractor Name LZ <br />Phone # - (i <br />TContractor <br />Address r97.� '{� l <br />CA Lic # 774 `i Class <br />R <br />A <br />Insurer <br />Work Comp # <br />cICC <br />T <br />Technician's Certification Number G <br />J ''Vr <br />Expiration Date <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />❑Approved uApproved with conditions ❑Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name ry Date 01 <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 <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />ORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />THE PERFORMANCE OF TJNI <br />WORKER'S COMP WS F CALIFORNIA." <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "ICERTIFY <br />THAT IN THE PE ORMAF T W RE FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />OF CALIFORNI ' COMPENSATION LAWS <br />. <br />App licants Sign Title 1 n .e Y + Z I • ® ! <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 by signature and date below. <br />NAME TITLE PHONE # <br />ADDRESS <br />SIGNATURE <br />EH230038 (revised 818/06) <br />0 <br />