Laserfiche WebLink
Sep 22 08 10:38a Reliable Petroleum 209-845-8953 p.4 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton, California 45202 <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. INCICATE Pr RMIT TYPE BELOW <br /> TANK RETIROFIT r 'PIPING REPAIRIRETROFIT UDC REPAIRIRETRCFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# <br /> A Project Contact&Telephone# <br /> C Facility Name PhonefRJI <br /> I Address I 12:- <br /> I Cross Street <br /> T <br /> Y Owner/Operator 1 ','� G_:r.a•f_ F c lja�'• ? Phone# <br /> c Contractor Name I r } f <br /> 0 �1L�R'�C t� ��c�kr r.4'�y'-E-- Phone <br /> T Contractor Address 1 G�WLC tY rn - CA Lic# )5 V Class <br /> A Insurer �)L Work Comp# t <br /> OCC Technician's Certification Number S Its <br /> fit' 5-1 l�,T Expiration Date � <br /> a ICG Installer's Certification Number - <br /> R `� U t� Expiration Date '57,10-id f <br /> Tank ID# Tank Size Chemicals Stored pate UST Installed <br /> C u rren tly)P revi ously <br /> T Crc e_ i�)-lc'c0 -Sc•�,'� <br /> A <br /> N <br /> K <br /> P ❑Approved pproved with conditions Disapproved <br /> L (S Attach Wrth Conditions) <br /> At6� �-7 <br /> Date 12 r,� <br /> N Plan Reviewers Name �- U <br /> /,:�i <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS,ANO 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 SMALL NOT EMPLOY ANY PERSON IN SUGH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WA K FOR WHICH THIS PERMIT IS ISSUED,f SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CAL!FORN IA." i <br /> ApgllcantsSignature rl-�` d..{. 1( t Tide'��'r- ✓ J 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 /> EH230038(revised 12131107) <br /> 1 <br />