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Jul 01 10 11:55a Reliable Petrole 20.&5-8953 p.3 <br />ENVIRONMENTAL T <br />SAN J AUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 CAYS FROM THE APPROVAL DAT I— INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ,WPIPING REPAIR/RETROFIT ❑ UDC REPAIRtRETROF'IT ❑ COLD STARTIEVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Icrt ►'n �ta>' 2B 9-601-933 <br />I <br />Facifity Name LJ 0.-�er too Fod A Flu �- <br />� <br />Phone # ,gyp 9- / lr Lv -Sg / Lr� <br />L <br />I <br />Address 3030 Z, U.)a-WIL)o <br />Ro" 5�%c--tun �iszos- <br />T <br />Cross Street <br />Y <br />OwnertOperator p, %A t 5i L, <br />Phone # dO%_ <br />C <br />a <br />NContractor <br />Contractor Name -� E S>,y <br />_ Phone # ,905?- fr (S-- FSg- Cp <br />T <br />Address ; i ► � �u r1 d i ��g <br />7 370 <br />CA Lic # !o Class A <br />A <br />RFr,4 <br />c <br />Insurer A/D <br />Work Comp # )3- 603 0 4p7 -v y <br />T <br />o <br />ICC Technician's Name G(,L a � <br />Sa h� �-z <br />L . <br />Expiration Date b 1 3U - j <br />R <br />ICC Installer's Name a d.Ol ti <br />� `C <br />J1'l,>;Z- <br />Expiration Date 01-/57-11 <br />Tank system work area <br />(i.a 87 piping sump, gt ie deEeCtor, UDC 7.2 etc.) <br />Tank Size <br />Chemicals Stored Currently Date UST <br />T <br />htSC- 0)1C F, Ik S iIt VLC.I <br />t.�vti[ <br />Installed <br />N <br />97 Lim U0-y-uYtV_ <br />,c�S�1 i atm Ctt�JL <br />Vt:) L S e.1,1 SU i2 -S <br />vA v� K- <br />7_a <br />P <br />L <br />A <br />N <br />Plan Reviewers <br />Approved <br />® proved with conditions Disapproved <br />(See Attachmen` h C di ' ns) <br />l� ®✓ <br />HN <br />APPLICANT MUST PERFORM ALL WORK INVCCOR AAPkE WITH SAN JOAQUIN COUNTY ORD! N S, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEpN►ARTMENT. OWNER OR LICENSED AGENT SI NATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT !S ISSUED, I SHALL NOT EMIL ANY PERSON 1N SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKERS COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERT?FIES THE FOLLOWING. "I CERTIFY <br />THAT LI OR IA." PERFORMANCE OF THE'dVORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicanrs Signature <br />TitleDate 0,71W i 0 <br />BILLING INFORMATION: <br />Indicate the responsible party 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 />responsibility for the billing by signature and date below_ %� (J r <br />NAME 2 S TITLE V w h f— � _PHONE* <br />ADDRESS <br />SIGNATURE <br />DATE <br />EH230036 (revised 02!20109) <br />1 <br />