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Aug 25 08 09:16a Reliable Petroleum <br />209-845-8953 p.3 <br />0 <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL <br />II DATE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT _PIPING REPAIRIRETROFIT L_IUDC REPAIRIRETROFIT OLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # kj'ek r Z _i(r,W, <br />A <br />c <br />CCE Facility Name <br />Phone #U 9- --') 3 <br />Address s'�U55 uL� ! U -t'h/ <br />T <br />Cross Street > <br />Y <br />awnerlOperator I ea it 2 (D 1 -L -q q O j .. <br />Phone # 202 / �� <br />C <br />o <br />Contractor Name �� lei ' G��G ujn �G (es -►-7n <br />- <br />Phone# �?fjQ- b MI5 5��p <br />T <br />Contractor Address <br />CA Lie N 13 70 Class <br />R <br />A <br />Insurer pC -_�c <br />C3 env', ►"'cf1 }1rlc'�'�! � <br />Work Comp <br />C-? <br />T <br />ICC Technician's Certification Number 5 5(j t -t) - (,Z "� <br />Expiration Date 'a La Y� <br />R <br />ICC Installer's Certification Number yj.�7 j f L it <br />Expiration Date f / 7 / O l <br />Tank ID # <br />Tank Size Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />N <br />F e ' T� t ��>r } r - �- <br />`/ r -e I`i�+tom �� L . <br />,- <br />K <br />-D Cc S C L_ -- -�.a <br />It ;< S -t` - <br />P <br />JApproved [Approved with conditions ❑disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST 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: 'I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHfCH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSAT N IAW3 OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY <br />THAT IN THE PERFORMAN E OF THE RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." � f <br />Applicants Signature <-� Title V del OaEe + <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional END stats time expended beyond permit payment coverage per tank. If <br />the party ignated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility f r the bills y signature and d e below. <br />NAME /�ti' %C Lf TITLE _(�V C( Di PHONE # 267 <br />SIGNA <br />EH230038 (revised 1213l/07) <br />11 <br />