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I <br />A <br />T <br />A <br />N <br />K <br />% 0 0 <br />77NVIRONMENTAL HEALTH DEPARTMEN'" <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 1 <br />Jill <br />V 1� III WILIF.M.ThM <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT —1PE SELOW. <br />TANK RETROFIT 0 PIPING REPAIRIRETROFIT 7 UDC REPAIRIRETROFIT [I COLD START/EVR UPGRADE <br />PA Site # <br />acil;ty Name <br />Address <br />Cross Street <br />Owner/Operator <br />Contractor Name <br />�d L'-7 <br />Project Contact & Telephone # <br />Ca <br />Phone <br />Phone 9 <br />Phone 06�- <br />j.1 CA i # <br />i. Contractor Address Class <br />Insured! Work Comp <br />!CC Technician's Narne4.1--,S Ll y Expiration Date S- 2,3- 1 <br />!0-11 instafler's Name <br />Expiration Date <br />Tank system work area <br />i sir ;�Pmq 9! UM; 10. ("T. <br />Tank Size <br />Date <br />Chemicals Stored Currently I InstUST <br />alled <br />Approved <br />I i Approved with Conditions Disapproved <br />(See Attachment With Conditions) <br />,"I 2;lan 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 />10 OUI1 Tl 1E i 'G� "I CERTIFY I <br />J A N COUNTY. ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFI�iS - F 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 SEL;U1,rL- txUbiLut i <br />TO VVC,'%,KER'S COMPENSATION i CALIFORNIA." CONTRACTOR`S HIRING OR SUBCONTRACTING SIGNATURF CERTIFIES THE FOU.CWiNG: "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 />Or CAL15ORNIA." <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional eHD staff time expended beyond permit payment coverage per tank, !f <br />the partv designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsGi5ty for the billing by signature and date below, <br />ADDRE33 <br />SlGNA"URF___,__ <br />EH23003a (revised 02120/09) <br />TITLE PHONE k <br />1 <br />