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Ja, 4 13 09:55a Reliable Petroleun-A 209-845-8953 p.3 <br /> EN IRONMENTAL 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=ROM THE APPROVAL DATE. INDICATE PERMg TYPE BELOW: <br /> C TANK RETR IT C PIPING REPAIRIRETROFIT O UDC REPAR RETROFIT COLD STARTIEVR UPGRADE <br /> F EPA Sire Project Contact&Telephone#& I �(� <br /> � Facility Name Phone#49 U - 9 .r-2 <br /> � Address S <br /> TCross Street <br /> Y OwneoOperator i( I Q,K Phone# go -yy y--2,4L/ <br /> o Contractor Name ( a,joi a ( (Phone# <br /> T Contractor Address j 430 4 cAul 0 &,370U class <br /> A Insurer Work Comp#105 Q a60 <br /> G <br /> T ICC Technician's N imeG Z, Expiration Date 0 _ <br /> R ICC Installers Na San 01, Expiration Date Jam.p 1 — <br /> Tank Sys ent work area Tank Size Chemicals Stored Currently Date UST <br /> he In F'rylne amp, lack tleleebr,❑OC 1R,ex.l y� Installed <br /> T d^' -S �tjJ <br /> N <br /> K <br /> P ❑ proved — pproved with Conditions ❑ Disapproved <br /> L (See ant With Conditions) <br /> N Plan Reviewers Nae <br /> PPUCANTMUST PBtFORM A WORK.N ACCOROAN TH SAN JOAOUIN COUNTY ORDINANCES STATE LAWS,AND RId.ES AND REGJLATICNS OF SAN <br /> JOACUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AG°NTS SIGNATURE CERTIFIES THE FOLLOWING: "I CPRTIFY THAT IN <br /> PERFORMANCE OF THE' RK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> A7RKEN COMPENSATION U n OF CALIFORNIA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATLRE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> 'HAT IY THE PERFORMANCE C THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA' , <br /> «� nn <br /> APPItaM's SiOr®lue life Dela — <br /> BILLING INFORMATION: <br /> Indicate the responsible rty to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated be w is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibilq for the bil_lin by signature and date cw. (/ ,`e 1 7�� <br /> NAME I�=+�,p E t _ 1'_PHONE# r .Y'. / t)q-q-34P3 <br /> ADDRESS f JL� ,1V_ C�-• .aT;L "V/ lj�'l ' .f �� 1 <br /> SIGNATURE --0' A DATE_ <br /> EH230098(revised 0811!i 1) <br /> 2 <br />