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Aug-07 12 03:08p Reliable PetroleumA 209-845-8953 p.4 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, Califbmia 95202 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> 3 TANK RETR <br /> THIS URMIT EKP <br /> 'RES 180 DAYS FROM THE APPROVAL CATE. INDICATE PERMIT TYPE BELOW: <br /> IFIT APIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT 0 COLD START/EVIG UPGRADE <br /> F EPA Site# <br /> A Project Contact&Telephone <br /> C Facility Name A Phone A <br /> L Address <- <br /> I Cross Street stre le� I r a. <br /> T <br /> Y OwnedOperator <br /> Contractor Name e <br /> n Chone# <br /> N Contractor Addres )N , & -.1 1 l <br /> rf-4,r <br /> P <br /> ZA Phone# 90,7— <br /> T s q3 1) <br /> R CA Lic# Class <br /> Insurer <br /> A f,- <br /> 12& C Work Comp# <br /> T ICG Technidan.s N meti/a—10 <br /> 0 Expi ration Date <br /> R ICC Installer's Nam Expiration Date q— <br /> Tank sys am work area <br /> {!a 87 pipingsure 9 *ak oetecbr.icc m, Tank Size Chemicals Stored Currently Date UST <br /> Installed <br /> A <br /> N <br /> K <br /> P ❑ .4 pproved Approved with conditions <br /> L Disapproved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Na rr a Z11),191 <br /> 24 1 141 Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY CRDiNANCES,STATE LAWS,AND RILES AND REGULATIONS OF:SAN <br /> JOAQUIN COUNTY,ENVRONIVEf ITAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE A G CERTIFY THAT I <br /> THE PER'S OF THEW K FOR VJIHICH THIS: FOLL0 qN . 'I C IF N <br /> WORKER'S COMPENSATION LAI) PERMIT is ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SLBJECT TO <br /> 'S OF CALIFORNIA:' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE;OLLCIAOING: 1 CERTIFY <br /> 7HAT IN THE PERFORMANCE OF HE WORK FOR WHICH'HIS PERMIT IS ISSJE:>,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> "Appficant's Sllgiztur-e <br /> BILLING INFORMATION: <br /> Indicate the responsible pa ty to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated bels v is different than the permit applicant e.g, property owner, the party must acknowledge this <br /> responsibility for the billing I y signature and date below. <br /> &-nL q <br /> NAMEkhT <br /> d� L PHONE#-6x,? <br /> ADDRESS—USXr .0 A <br /> SIGNATURE <br /> EM230038(revised 0811111) <br /> 2 <br />