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May 31 12 09:35a Reliable PetroleumA 209-845-8953 p.13 <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 /> PPLICATIONFOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> Trl 8 PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIRlRETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/I UPGRADE <br /> F EPA Site# Project Contact&Telephone <br /> Facility Name R Pk— A w\ Ni Phone <br /> L <br /> Address y%SS 5�az e acp `1 <br /> TCicss Street <br /> Y Owner/Operator ." 9C0 `IT,(g'— Phone#Ajl-f0�-L 3F <br /> o Corrtractor Name i i lk e (}e YUtt�Lvt $LYv, �C• I PhoI-FI1T'?'58 r-p <br /> N <br /> Contractor Address I Y CAUCIIi 9X71-7o(0 Class <br /> R Insurer Work Comp# ?/�_ lP--zpo <br /> A <br /> T ICC Technician's Mame Expiration Date Q LJ--Z3/,3 <br /> o ICC Installer's Name Expiration Date )y— 1 IZ <br /> R <br /> Tank system York area Tank Size Chemicals Stored Currently Date UST <br /> p.e:sT prylnp surtp.911eatc tegor,u0c lrz.mc.) installed <br /> T 9 4k yve <br /> A <br /> N <br /> K <br /> I <br /> P ❑ Ap ed EWA with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A — <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL W RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,SATE LAWS,AND RULES AND REGULATIONS CF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTA HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK OR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS F CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY <br /> THAT IN THE PERFORMANCE Or TH WORK FOR WHICH THIS PERMIT is ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> vvlKam'sSlgnature <br /> BILLING INFORMATION: <br /> Indicate the responsible party c be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below 3 different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by gnature and date below. �1 L l,��J p p <br /> NAME yr'r �'XV. TITLE ONn f f-�')tr PHON <br /> E 0,4 4L)r- b P <br /> ADDRESS 1`1 �G�. ( Cl G3(. ) <br /> SIGNATURE' S"" " DATE <br /> EHT.f M(revised 0811/11) <br />