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May 19 08 03;01 p RELIABLE PETROLEUM SERVIC 2098458953 p.4 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN <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 /> O <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> OTANK RETROFIT • PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> >= EPA Site# Project Contact&Telephone# <br /> C Facility Name Phone <br /> L Address l 95 ;3r) <br /> Cross Street U <br /> Y Owner/Operator 5o&-�N I Phone# <br /> a Contractor Name �0-y 4-- Phone# <br /> T Contractor Address j l 16rc,- 1 i - CA Uc Class <br /> A Insurer f�C 1�n V f rO k'1 klyttklfa,(2� Work Camp# <br /> T ICC Technician's Certification Numbers j Gj�s� Lk--- Expiration Date 0- -617_G <br /> R ICC Installer's Certification Numberrj�j (,t <br /> �5��-J().- � Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T - 12 oa q �a.Sa( t _ <br /> A <br /> N <br /> K <br /> P ❑Approvedroved with conditions ❑Disapproved <br /> L S ' achment With Conditions) <br /> A <br /> N Plan Reviewers Name Date S <br /> APPLICANT FAUST 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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY 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 BECOME SUBJECT TO <br /> 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 FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> Applicants Signaisus Date <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(revised 12131107) <br /> 1 <br />