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Nov 30 10 05:24p Reliable Petrol 0 <br /> A -845-8953 p.4 <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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> HIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW <br /> 0 TANK RETROFI "WING REPAIRIRETROFIT O UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# b pr1j �0 q-4p q q_ q-3 3 <br /> O Facility Name L '�1j1�Q <br /> � S HE LL Phone# _>?Ga y_y a 3 <br /> Address /(p� <br /> Hct►'�AI'1 LR-fhrOP c 15330 <br /> I Cross Street <br /> T <br /> Y Owner/Operator <br /> [Vi (-V- hm-ri Phone# do f-yo 3 -3 f S q <br /> C Contractor Name U beam <br /> O �I Icc�f>e S��d;�-es (_ . <br /> Phone dyS-85-S'lv <br /> T Contractor Address IIR30 �Ot' eSI�c3 <br /> 5 r CA Lic# gg 37 D� Cuss <br /> AInsurer F LA/P Work Com # p <br /> p ra36(c'78'-2-0d <br /> C Gb {�-T ICC Technician's Name Expiration Date <br /> vE <br /> If !q-! 2 <br /> R JCC Installer's Nam <br /> �o bef fir- Expiration Date 6q_2_2__/2_ <br /> Tank sys7 em work area Tank Size Chemicals Stoned Current) Date UST <br /> (i.e_87 piping s:mip,9 dt <br /> leakdeteor.UDC 1/2,etc) y Installed <br /> T 8�1 �1Q° S unk c:ctSvLiri�'_ ski <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions Disapproved <br /> A (Se Attachment With Conditions) <br /> N Plan Reviewers Nan ie <br /> Date <br /> APPLICANT MUST PERFORM AX WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONM=NTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING= "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE V fORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATIO LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'ICE r <br /> THAT IN THE PERFORMANCE C F THE WORK FOR 1AHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATfON LAWS <br /> OFCALiFORNIA." / //y/ <br /> Applicant's signature G� -' fit/ Title Date 1a G I 1 L <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff fime expended beyond permit payment coverage per <br /> tank. if the party designat below is different than the permit applicant, e.g. property owner,the patty must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> — ----- DATE <br /> EH23DO38(revised O7/22/10) <br /> 2 <br />