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Feb 1 i' ,12 08:22a Reliable PetroleumA <br />209-845-8953 p.20 <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 />IS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOUV <br />C TANK RETROFIfH E PIPING REPAIRIRETRO FIT ,D UDC REPAIR/RETROFIT ❑ COLD START/EVR tlpc;Renl= <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name LU i 1S >i� L(JGl <br />1 E G lid Yl Phone #, ?20 9412 - 2- 3 Cf � <br />L <br />Address /3ri f LIZ' SU <br />&YI <br />% LIQ. � /- ^ 9S`zU5" <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # G' <br />C <br />Contractor Name ' j <br />, prLG6 �' Phone # <br />v, t.e _1,1 C c�U 9- �5 yS - S <br />NContractor <br />T <br />Address 11130 Ut <br />S�IL� c CA Lic# Gass <br />RInsurer <br />A <br />-Sim-r— ii <br />Work Comp # 30(0 — ZDO q <br />T <br />o <br />ICC Technician's Nam �U.a <br />t° So r`t �(' Z Expiration Date o -23 -13 <br />R <br />ICC Installer's Name GLI Fit e scL-n C,1,1 Z-- Expiration Date 12- - <br />Tank system work area eta.) <br />87 piping sunp, 91 lea ceteotor UDC 1l2, .j <br />Tank Size Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />�d ri -F&.q K <br />-LI, tie Q <br />Ga_S l_..i <br />rt <br />N <br />A <br />N <br />K <br />i <br />P <br />_� Apr roved <br />Approved with conditions ❑ Disapproved <br />A <br />e AttaGtment With C nditions) <br />N <br />Plan Reviewers Name <br />i' <br />Date <br />APPLICANT MUST PERFORM ALL 04/IN ACCePAI�E: <br />JOAQUIN COUNTY. ENVIRONMENT L HEALTH DNT. <br />PERFORNIANCE OF THE WOR FOR WHICHIS, <br />WITH SAN JOAQUIN COUNTY OR A ES, STATE LAWS, AND RULES AND REG SLATIONS OF SAN <br />OWNER OR LICENSED AGE IGNATURE CERTIFIES THE=OLLOWING: "I CERTIFY THAT INTHE <br />IS ISSUED, I SHALL NOT EMP 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 OFT E WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT <br />OF CALIFORNIA." <br />TO WORKER'S COMPENSATION LAWS <br />Applicant's Signature__�rTitla ' til ,Yii(L (1/,r'i ��. 1 i �- 1 I LD !I 7 _ <br />BILLING INFORMATION: <br />Indicate the responsible part to be billed for additional END 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 fro, rjth+e billing by signature and date below, <br />NAME ` IITLE��j HONE #_ gg% q gq 5 - g c5 -p 6 <br />ADDRESS <br />SIGNATURE <br />EH230038 (revised 08!1111) <br />. 2 <br />A _ gs <br />