Laserfiche WebLink
May 1214 09:16a Reliable Petroleum <br />0 <br />2098458953 IDA <br />0 <br />ENVIRONMENTAL HEALTH DEPARTnRbEIVED <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 MAY 13 2014 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 ' <br />APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENT <br />ALTH <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PEFWrT EXPIRES 1 SO DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br />D TANK RETROFIT D PIPING REPAIRIRETROFIT b UDC REPAIRIRETROFIT (SXCOLD STARTIEVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # f�- 9- 41011- 47 ?2 1 (1e, <br />A <br />C Facility Name "�p5CN11.t tC, r? Lp Phone # 90 y — 9 a'3-. LG <br />L <br />i Add rens + 1 L S f i'Vtl +-C, C4 g~ 3 <br />TCross <br />Street <br />Y <br />Owner/Operator ct Phone # 499_ 9,L 3 -2 & <br />cContractor <br />0 <br />Name L 1 V r Phone # � <br />N <br />Contractor Address lkgb CA 1 is # t�3'7d Class <br />R <br />A <br />Insurer '5187E F(A N b work Comp # 941%1595-F'- 20I <br />c <br />ICC Technician's Name r �' Expiration Date ULI - 2,0 •-/5- <br />R <br />ICC Installer's Name c,-�Uac &. 'J ft m (c;he Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak deleaor. U00 V2, eke.) <br />Tank Size <br />Chemicals Stored Currently Date UST <br />Installed <br />T <br />A <br />N <br />K <br />I <br />P <br />C Approved pproved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />I <br />Plan Reviewers NarnQ �� � ��aI1 Date _n(.N l l <br />APPLICANT MUST PERFORM ALL VVORK 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: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERM 17 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 PE S ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA" 10 <br />Applioanrs Signature n %` �Kti.� Date ii J �L l <br />c <br />BILLING INFORMATION: <br />Indicate the responsible party to be bill 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.ox <br />NAME I�{'tr }" '�1 i - �-xLi' n l I cl-6= TITLE ('/)n frA Ch9 PHONE <br />