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Mar 30 12 02:27p Reliable PetroleumA 209-845-8953 p.4 <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 /> APPLICATIOMFOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> HIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROR ❑PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name ,t,'lci{h �{�.-� Phone# <br /> I <br /> L Address I I�,G S, ?W0.I VA rr- <br /> 1 Cross Street <br /> T <br /> Y OwnerlOperator 4J-1 5 .ay-rna Phone# -20 g 2 <br /> C Contractor Namer(tJj� � .�,j��lyl C _ <br /> o JeYv c�5 — Phone# p 7 <br /> N Contractor Address q <br /> T 1 3D 1.1o�5�SL1-c-t✓ t'�-�' 9s3iP! ICALic# ,��370Cc Class <br /> AInsurer 5{' <br /> C Work Comp# 7/'--',- <br /> T ICC Technician's Na ��au�ix�v` Sa�tiG)t�z Expiration Date OV - 2_��-13 <br /> R ICC Installer's Name t , <br /> �. S�{f l GING Z. Expiration Date f - 2 <br /> Tank syster work area Tank Size Chemicals Stored Current) Date UST <br /> (te.87 pipi%sump,91 le delectar,UDC 1r2,etc.) y Installed <br /> T CVQ n-e u n,IC <br /> A <br /> N <br /> K <br /> P ❑ Ap roved Approved <br /> with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name / <br /> Date <br /> APPLICANT MUST PERFORM ALL VIORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENT L HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN + <br /> THE PERFORMANCE OF THE WOR FOR WHICH THIS PERMIT;S ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> b RKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF 71 E WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> App:icant'sSi;nabur> Date 03 3o IZ <br /> BILLING INFORMATION: <br /> Indicate the responsible part to be billed for additional END 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, rrff �jI('� <br /> NAME 1 'f ! 1 TLE (Ahtr1k,C rPHONE# ��I' n S - <br /> ADDRESS <br /> SIGNATURE <br /> DATEQ2, �- <br /> EH230038(revised 08P 111) <br />