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Jun 10 09 04:53p Reliable PetroleumA 209-845-8953 p.4 <br /> 0 0 <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 /> 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 REPAIRfRETROFIT ❑ UDC REPAIRIRETROFIT Q CGLD STARTIEVR UPGRADE <br /> F EPA Site Project Contact&Telephone# F-G)bas�+Fjc�`nha� aL'� -93 <br /> C Facility Name A�-I�-' Phone <br /> L Address S� V. J__j4 , �l'Cc�t }rG c 17s-3 p <br /> TI Cross Street <br /> Y Owner/Operator j 0. 01 ra if La Phone# 610- y/LI-S 3 90 <br /> C CorttractarName i imp +>vttit S�YVi C. Phone# pcjl _ �°yS- �5 � <br /> T Contractor Address,_52 -rL`►^ CA Lic# �� (.� class <br /> R Insurer <br /> .`j �AT E work comp# d 8' <br /> T ICC Technician's Name <br /> Expiration Date v <br /> R ICC Installer's Name C,,U G�C ��L 2AY� Z_ Expiration Date <br /> Tank system work area sump. Tank Size Chemicals Stored Curren Date UST <br /> F.®.97ppirsump.41 teakde�etOr,tJOC'iTd,etc.) Currently IfiSt�ed <br /> T f! :ti _ -12-10Q C? i 5 Z_ Lih y- rl <br /> A <br /> N <br /> K <br /> t 77— <br /> P D Approved Approved with conditions ❑ Disapproved <br /> L <br /> A S 'Attachment With Conditions) <br /> 94 <br /> N Plan Reviewers Name () <br /> Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH 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 '7 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FQF WHICH XHIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" /� F <br /> Appka-'s Signatt,re LJ, CV��t �?U A I '��%� Date r '/0—6 <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 /> EH230038(revbed 02120109) DATE <br /> 1 <br /> I <br />