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ENVIRONMINTAL HEALTH DE <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />•• rr *17611111 r •-. .� - <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br />F <br />EPA Site # 5 j <br />Project Contact & Telephone # .�_ of LL kF moLi <br />A <br />C <br />Facility Name vy' IP`,r p r c e r S <br />Phone # -4-4 - <br />Address qq C L 1 e -r,.•t t <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator %jn I lFt E e- 4 r 5 Phone #, '3 tr 00 <br />o <br />Contractor Name —' v7 1 <br />Phone #Sf2iZ _ <br />N <br />T <br />Contractor Address , , CA Lic # L573 1 Class <br />O 1 1C r1 f3u 0 Cs )j <br />AInsurer <br />° 6�� �, L <br />Work Comp # <br />T <br />ICC Technician's Certification Number iZ�j '�, — T <br />Expiration Date C? <br />RICC <br />Installer's Certification Number Q [ <br />Expiration Date 3 C3q <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br /># f <br />to X <br />1 <br />kn <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 <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 UIMICH THIS PERMIT IS ISSUED, 1 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 PERFORM E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />6 <br />Applicants Signature Title Date t <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 />-T <br />^ y <br />NAME Y)V s n QcX e TITLE PrP:S —PHONE* 7 - 1- ' <br />SIGNA <br />EH230038 (revised 12/31107) <br />1 <br />1 <br />