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Oct 13 11 05:05p Reliable PetroleumA 209-845-8953 p.4 <br /> • <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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE AFPRCVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETRO IT D PIPING REPAIRIRETROFIT O UDC REPAIR/RETROFIT XCOLDSTARTIEVIR UPGRADE <br /> F EPA Site# Project Contact&Telephone# . + ( <br /> FacilityName C (tr t( kv e Ch e ve-owl Phone# <br /> L <br /> Address 510 k/, C.11etr f-C, G✓9� 5t z:4fnn CA Y5-'24l <br /> TCross Street <br /> Y Owner/Operalor Yi IL�1.t�Y' S 1 I,1 SGt Yt.i Phone# aG 9y2-1'7 34 <br /> p Contractor Name Wie b)er Se,-V,,( e S �, Phone# 2?5 <br /> N ContractorAddres ilg3t] i'Sc'ShC:✓ CAur# Class <br /> T <br /> R Insurer Sty- Work Comp# 04)3a4,7f 200 <br /> A <br /> D ICC Technician's N mer, .SQvi Expiration Date�ygplfg <br /> T <br /> ICC Installer's Nam "u Expiration Date 572,5C) `l51—V 1 <br /> Tank sys em work area Tank Size Chemicals Stored Currently <br /> Installed Date UST <br /> p.e.e;am�e sure. Iaakaeteclor,voc 1rz,enol <br /> 1 <br /> T <br /> A <br /> N <br /> K <br /> I <br /> P 'J pproved proved Mdth conditions :1 Disapproved <br /> L (See ch ent With Conditions) <br /> N Plan Reviewers Na ne Date ��//1,1 <br /> APPLICANT MUST PERFORM A 11 WORK IN ACCORDAV I H SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONN ENTAIL HEALTH DEPARTMENT.O-ANER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERT FY THAT IN <br /> THE PERFORMANCE OF THEV DIRK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION w'S OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTI=Y <br /> THAT IN THE PERFORMANCE F THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SJBJECT TO WORKER'S COMPENSATION LAWS <br /> OP CALIFORNIA." <br /> Applimri!'s Signature � �r -� Date �O 13 <br /> BILLING INFORMATION: <br /> Indicate the responsible arty to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the pary designated b ow is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibilit for a billi by signature and date below. <br /> t <br /> 1Z� PHONE C/y, i U lTITLE YZ <br /> ADDRESS /17 <br /> ' 14'lr� — A- t� <br /> SIGNATURE _____PATE1 I%3 ISI <br /> EH230038(revised 0811111) <br /> 2 <br />