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Mar 31 09 11:29a Reliable PetroleumA 209-845-8953 p.46 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 9202 <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 INDICATE PERMIT TYPE BELOW' <br /> ❑ TANK RETROFIT PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name n —r <br /> � Y ��l.� l Mt�12T -7(-o Phone '# �pq-�3Q- 7777 <br /> 1 AddressJ+ <br /> i HCl' h a55 /ROfJ� �1'0.0 C# <br /> T <br /> Cross Street <br /> Y Owneri0perator Phone# <br /> C Contractor Name doCl 873 O— r r7`?q <br /> N R���� I1 �IT� Phone#Z)0c1 - �Uy-G3� <br /> T Contractor Address Sal CA Lic# �' 3 7U (p Class <br /> R <br /> CInsurer T C Work Comp <br /> T ICC Technician's Name 'j? 0 9 5 1 U 1~ Expiration Date <br /> a ICC Installer's Name <br /> 1 a 5 — u Expiration Date S 0 U <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e 87 piping sump,91 IeaK detecwr,UDC 112.elc i Installed <br /> T 'U- 5ha►'1 ri L L 10000 <br /> A GQ50 11"a ��1LctidW <br /> N <br /> K <br /> P ❑ Appr ed Approved with conditions ❑ Disapproved <br /> L <br /> A (See ttachment With Conditions) <br /> N Plan Reviewers Name <br /> Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE MATH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING' 1 CERTFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO SUBJECT <br /> TO WORKER'S COMPENSATION LOWS OF CAUFORN1A' BECOME CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CE+?TIFIES THE FOLLO'MNG: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ) JII ,}—, ,r (ry /, q <br /> ApplicasSigrrahire W U UNI:/ ✓LIQ 4n <br /> rrt -l� <br /> L30Jv <br /> Dale <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 /> DATE <br /> EH230038(revised 02120!09) <br /> 1 <br />