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Oct 02 08 11:37a Reliable Petroleurn 209-845-8953 p.4 <br /> 0 • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT 12r1PIPING REPAIR,RETROFIT ❑LDC REPAIRIRETROFIT ❑COLD STARTiEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name ; Phone# 09- 4 F:;, <br /> L Address 4tOO S. Air ,U� �� �� }rl CA, Q5-2_QU <br /> I Cross Street <br /> T <br /> Y Owned0perator —T_k0 -, 5 Phone <br /> o Contractor Mame ' ����} 6cx nhG`r-�- Phone#06q 4,oIN <br /> Contractor Address CA Lic# � 3- 0� Class <br /> R Insurer <br /> A �L E►1tir;wrt;sl v�te,i�t�t}.,�. Work Comp# N� <br /> C ICC Technician's Certification Number 'j (7 k-151 - CA"T' Expiration Date 71d io q <br /> T <br /> o ICC installer's Certification Number r' t� <br /> R `��}��-rj �(�— �« Expiration Date �� � 9' <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> N T rA.V1 K _4'_2v Q Te-rl V-k*_�--- <br /> K Tt Vt 3 ,) oU G 3`�t A r--7wet <br /> F� ❑Approved ❑Approved with conditions ❑IDisapproved <br /> L (See Attachment With Conditions) f <br /> N Plan Reviewers Name Ll��it�^4�L ll r(l!/.ItiA., Date44-1,4� Zq-`�!a g <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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLCY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CAUFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN T.-iE PERFOR C OF THE APORK F R WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Wq <br /> rLr6LU r,AppliCartts Signatura L " Title Date `� <br /> BILLING INFORMATION: <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 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 TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH 230038(revised 1213110 7) <br /> 1 <br />