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I�j <br />El <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 # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name <br />Pho # - <br />09 <br />Address 140 LAD4 WP 6 a <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />o <br />Contractor Name i <br />Phone # - '' <br />N <br />T <br />Contractor Address A Lic # Class <br />A <br />Insurer AM MWZ COMPANY OF AMEZCA Work Comp #WW50910(171500 <br />TICC <br />Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />17-1 <br />❑ Appro ed Al Approved with conditions ❑ isapproved <br />L <br />fQmlevachment With Conditions) <br />A <br />dho <br />N <br />I wk--� — <br />Plan Reviewers NameI - ---- ----- Date --- <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CO TY 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 <br />TO 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 />Applicant's Signature__ _— _ _ Title_ S� —16 --Date <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional END 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. i' Lr'1 w t6 " ,/ ��[] ,/� "j <br />NAME I (!_C!010 _LNL --- TITLE-- 1_ T+-V�_—_PHONE 2, -WI 6 -------------- <br />/Vi _____ <br />ADDRESS- - _JAL-L2--_S.LIJ _ e-5------------------- <br />SIGNATURE_—_ --_- - P <br />-- --------------------------------------- DATE --2 -- <br />EH230038 (revised 02/20/09) <br />A <br />