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Oct 23 09 06:13a Reliable Petroleum: 205-8953 p.4 <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 ISO DAYS FROM THE APPROVAL DATE INDICATEPERMITTYPE BELOW: <br /> TANK RETROFIT ❑ PIPING REPAIRIRETROFIT Q UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> P EPA Site# Project Contact 8 Tel p 4 ri �- bot-i-933(0 <br /> Facility Name CL W0. 'CVr,0V1 Phone#o7�,q- qL-��3 <br /> 1Address 51)� W- G � <br /> L <br /> z ' Cross Street Phone#o7.O q` y F Z - 17 S <br /> Y OwnerlOperator S rn S/L f _ <br /> c Contractor Name 1 f Ovl 'fj'�{LPLL- -{ APhone#3L <br /> N CA Uc# O j 70 Class <br /> Contractor Address y"2 ( pL I ! !- ✓t S <br /> T <br /> R Sfia� Work Compile .3 13 <br /> A Insarer _ <br /> c Expiration Date- 04- 30-11 <br /> T ICC Technician's Name Gu _ tC J �� <br /> Expi anon <br /> o Date <br /> R ICC installer's Name Date UST <br /> Tank system work area Tank Size Chemicals Stared Currently Installed <br /> (i e.87 ppinq SUMP,91 leak d6IWVr,UDC t/2,eta) <br /> T q1 <br /> F-;1.1 75 t3. ai. A{" 2 00 ttYtlt �QSO�iI� �- tAr�K <br /> A <br /> N <br /> K <br /> Approved Approved with Conditions Disapproved <br /> P (See Attachment With Conditions) <br /> A � Date D <br /> N Plan Reviewers Nam <br /> APPLICANT MUST PERFORM ALL WORK 1N 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 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 TH'e FOLLOWNG: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO'NORKER'S COMPENSATION LAWS <br /> OFCALIFORNIA*' 10 <br /> Applicants Signature Tihe aDL� Date <br /> BILLING INFORMATION: <br /> Indicate the responsible parry to be billed for additional EHD staff time expended beyond permit payment Coverage per-Lank 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 /> DATE <br /> SIGNATURE <br /> EH23OD38(revised 02120109) <br /> 1 <br />