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Jun 01 12 02:53p JP Petroleum Service <br />916 372 4873 p.2 <br />0 <br />SAN JOAQUIN COUNTY <br />glit, Wjgj� I gin �treet, Stockton, California 9620 <br />11MR-1-MR Rem 7-32F M1. <br />0 <br />Tr <br />:411 a 4 -1 ill I I <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERWITTYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIRiRF-TROFIT o UDC REPAVE MTROFIT o COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />A <br />Project CorrW & Telephone ;V <br />A <br />C <br />FaciNty Name <br />Phone N6 <br />I <br />L <br />Address vc-K-A M. Xl q6161 <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # <br />C <br />Contractor Name <br />1Phone <br />N <br />T <br />Contractor Address � <br />CA Lic # 9-04171 Class qa <br />R <br />A <br />Insurer INV—k— <br />Work Comp <br />C <br />ICC Technician's Name <br />Expiration Date <br />0 <br />R <br />ICC Installer's Name <br />Expiration Date t <br />Tank systern wwrk area <br />(jm- Er7 pipkV =M, 01 I=k de LUC Nx ate) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Ins4alled <br />T <br />(264 D9RiL5Fz- <br />/b.( 6r2 -1b <br />OA Altst, <br />A----- <br />- <br />N <br />K <br />P <br />U Approved proved wfth oDndhions J Disapproved <br />L <br />See AlwhmentWith Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK 1ACCORDANCE VWTH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, EWARONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CER-nFIES THE FOLLOWING. "I CERTIFY THAT IN <br />THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH 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 V*qQH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA" <br />&�Ayy— <br />Appli nra Signabu Me <br />M <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 Wow is diffierent than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibli , for g�illlng by signature and date below. <br />D - - 0 <br />NAJ MILE PHONE # <br />ADDRESS , cs, r-1 <br />DASIGNATU TE TE U // <br />06/1111) <br />2 <br />