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Oct 26 12 09:56a Reliable PetroleurnA 209-845-8953 p.4 <br /> EN IRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, Cailfornia 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 APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> t7 TANK RETR IT D PIPING REPAIRIRETROFIT b UDC REPAIR/RETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# ProjedContad&Telephone#G, J4 .L�•• z lack-93ra3 <br /> A <br /> C FacilityNama bF 2r�.AD �O Avo-f-im Phone# go9-9YOC-2Y3k <br /> � Address NY6S S' P �.DL�-Q �9 <br /> T Cross Street <br /> COwner/Operator i� 0.r.aF1{l Phone#o'!py-qy(r-ay3c' <br /> o Contractor Name licl.bl•Q to >, s' v,"S1i1C• Phone#2tj9—SYS—S'rj`b'(p <br /> T Contractor Address 11q3Q 16-w65ko-c 1 -c sj CALic#. 943711 Class } <br /> K Insurer S <br /> A <br /> Work Comp#7!'3-30(Fly -aL+n}i <br /> T ICC Technician's N me P Expiration Date <br /> R ICC Installer's Nam Expiration Date J Z_I E_—17 <br /> Tank Sys m work area Tank Size Chemicals Stored Currently Date UST <br /> u a ez myna at Oak oetea«,uoc W.«cl Installed <br /> T �9 ST 'S GC�Sv t s1 <br /> A tl+ <br /> .� K <br /> N <br /> K <br /> P oproved Approved with conditions El Disapproved <br /> A {S men-,With Conditions) <br /> N Plan Reviewers Narr 1 Dam /122 J <br /> PPLICANT MUST PERFORM AL WORK IN ACCORD WITH SAN JOACUIN COUNTY ORDINANCES,STATE LAwS,AND RULES AND REGULATIONS OF SAN <br /> JOACUIN COUNTY.ENVIRONM AL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING; 'I CEFTIFY THAT IN <br /> PERFORMANCE OF THEW K FOR WHICH THIS PERMIT IS ISSUED,;SHALL NDT EMPLOY ANY PERSONlN SUCK'0.MANPFR A$TO BECOME SUBJECT TO <br /> KE R'S COMPENSATION LA OF CALIFORNIA` CONTRACTORS HIRING OR SUBCONTRACTING SIpNATURE CERTIFIES THE FOLLOWING: '.CERTIFY <br /> HAT I.Y THE PERFORMANCE OF 'E WORK FOR WHICH THIS PERMIT 15 ISSUED,I SHALL EMPLOY PERSONS SUEJEGT 70 WORKER'S COMPB.SATION LAWS <br /> OF CALIFORNIA.' <br /> Plimri'a , M111 a .' ._. "••Kn e3 t`j"' /'�`�'�Y L�.C%ty 1� <br /> lS Dae 10 "2(9-12.- <br /> BILLING INFORMATION: <br /> Indicate the responsible pa ty to be billed for additional END staff time expended beyond permit payment coverage per tank. It <br /> the party designated belo v is different than the Permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing I y signature and date below. _ 7 <br /> NAME \YL'1 lub"l �J•ii:a-T`kE [ni�"fYY.�C,L,\Z'r— PHONE* <br /> ADDRESS l t ri V 'r5'�5110-t IYA I/tai Cl l.Q Q 53(s I _ <br /> SIGNATURE -_ :'> ,. w DATE <br /> E11230038(revised 0&1/11) <br /> 2 <br />