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ENVIRONIENTAL HEALTH DEPARTMENT <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 # r -A 0948,Z E; D 7_5 1 <br />Project Contact & Telephone # >���- vt tL PF <br />A <br />C <br />Facility Name L),n' 1F1 IUD.- S1 A f ✓1 c rs <br />Phone #,3 <br />1Address <br />9C't'0 CLe-tI S+. SA,CL�Tc.nCA <br />TCross <br />Street <br />Y <br />Owner/Operator V,nt F%I G L:.orn afg-r _e f 5 Phone# ;x'3. ,,4_ 5 2.00 <br />oContractor <br />0 <br />Name ,� n c t e Phone #4 Z— -TO 2 <br />T <br />Contractor Address cy,o e i n / Lt Q, v , lei CA Lic # LQ 361 Class A <br />R <br />R <br />Insurer Fit ,,' n Z <br />Work Comp # L r <br />T <br />ICC Technician's Certification NumberEx <br />T <br />( p" ration Date (f — / 1 — j u <br />o <br />R <br />ICC Installer's Certification Number 5.2..5"2-� "" i,,,) 1 <br />Expiration Date <br />p -ZS ' <3 <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />( <br />/0 K <br />/ <br />f J i{ L <br />UPI k rt vt-Pel <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 <br />Name Date <br />V I I I/ <br />APPLICANT MUST PERFORM ALL WORK IN A&OR'DANCEVVMTH SAN JOAQUIN COU 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 COMPENSA-LION LAWS OF CAUFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFOCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />�//� 1 <br />Applicants Signature Title—410 PO 5 Date e <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for ad ' onal 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_ �� E»Ve nn >,-y ea ht TITLET i/ 5 PHONE TVC1 - 55 - -] 71'4' <br />SIGMA <br />EH230038 (revised 12/31/07) <br />tc,-v, RU,z /-%I -- ArneF, 12S KZ) vt--frs)z-e 0/3 92. <br />1 <br />