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Mar 19 13 12:23p <br />Reliable PetroleumA <br />I� 0 <br />209-845-8953 <br />0 <br />P.30 <br />E% <br />IRONMEN 'TAL HEALTH DEPARTMENT <br />SAN JOA UI COUNTY <br />600 East main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 183 DAYS FROM THE APPROVAL DATE <br />0 TANK RETROl rr INDICATE PERMIT TYPE BELOW <br />)(PIPING RtPAIR/l;rr <br />CUDC REPAIPJRMOFIT 0 COLD START/M UPl <br />F EPA Site <br />A <br />C Facility Name Cot <br />Project Contact & Tetephonl.414' <br />l CL%A-b Pkkl- k <br />1EE Phone <br />I Address I T- <br />L 5(o <br />#d4O f - <br />Co A� VL Ile i vot - <br />T I Cross Street <br />Y Owneri0perator <br />e <br />C <br />0 Contractor Name <br />-p- Phone <br />d <br />IN <br />T Contractor Address <br />Phone q - <br />R <br />insure <br />CA Lic -2-7c) ( Class <br />A <br />T ,ICC Technician's N <br />work Comp & Ll S I <br />R )CC Installer's Name <br />Expiration Date Cc(—L3�_, <br />OA Expiration Date Lt <br />Tank sys <br />(1.e.87rj;9ngswM,q1h <br />In work area <br />11kddectc(,UW1,ll Tank Size Chemicals Stored Currently Date UST <br />T 91 <br />A <br />Installed <br />PY'C <br />N <br />K <br />P Ap <br />m' —,W::2kpproved with conditions❑ Disapproved <br />A)See <br />Attachment With Conditions) <br />Plan Reviewers Namq <br />Date <br />APPLICANT MUST PERFORM ALL <br />JOAQUIN COUNTY, ENVIRONMENT <br />THE PERFORMANCE OF THE WO RI <br />IN ACCORDANCE %MTH SAN JOl COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />Ill HEALTH DEPARTMENT. DAWER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN <br />FOR VMICH THIS PERMIT IS ISSUED I SHALL NOT <br />ISSUED, <br />WORKER'S COMPENW, ION I.Al OF CALIFORNIA.- CONTRACTOR'S <br />EMPLOY ANY PERSON IN SUCH A MANNER As TO BECOME SUBJECT TO <br />OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -r CERTIFY <br />THAT IN THE PERFORMANCE OF T IE WORK FOR WHICH THIS PERMIT IS JSSUED, <br />OF CALIFORNIA." 'SHALL EMPLOY PERSONS SUBJECT <br />WORKER'S COMFENS,%TION! LAM <br />kPpleantsSinMure <br />A jk.-L— , -a <br />BILLING INFORMATION: <br />Indicate the responsible pa 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 />respfor the billing s;gnature and date below. <br />k L <br />NAME TITLE PHONEf J C—_ Pe— <br />IV — — lI — r(Z7 <br />=11112 <br />EH230038 (revised 08/1111) <br />2 <br />