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0 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <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 />ZTANK RETROFIT OPIPING REPAIR/RETROFIT 11UDC REPAIRIRETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone <br />A <br />C <br />Facility Name Phone # <br />L <br />Addres Id/ <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator <br />Phone# <br />C <br />Contractor Name Phone # <br />0 <br />N <br />T <br />Contractor Address CALic# & Class <br />R <br />A <br />Insurer <br />Work Comp # <br />C <br />T <br />ICC Technician's Certification Number <br />Expiration Date <br />0 <br />R <br />ICC Installers Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Date LIST Installed <br />Currently/Previously <br />T <br />A <br />N <br />K <br />P <br />[]Approved 1Approved with conditions []Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name flop lang Date to <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 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 FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.* <br />,< , <br />Applicants Signature -natuTitle 44awk Date - <br />pr– — 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 />NAM TITLE PHONE 0 <br />1 <br />A <br />