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Feb 17 12 08:15a <br />:1TANK <br />L <br />Reliable Petrole 45-8953 p.4 <br />4F <br />IR N ENTAL HEALTH DEPARTMENT <br />SAN JnAQUm C <br />DUTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />F �{ <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT — <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />IT D PIPING REPAIRIRETROFIT ❑ UDC REPArPJRETROFfT D COLD STARTIEVR UPGRADE <br />F EPA Site # Contact &Telephone # /+ <br />At�ttuG`I��tt�G9-(�-`�3�r;= <br />C Facility (Name Uj i )Oyj �� t � V r�Prqject <br />Phone # ;20 ZY 2- 2.396- <br />L Address Lft 9 L✓l CSl1Y) y�Q S (•,� � � 9S 2U5" <br />I Cross Street <br />Y OwneNOperator yI e <br />C ) Phone # ti E <br />o Contractor Name �(J < <br />i� .�. 1vL�4AJ V BVIG>°S '1C. Phone#aUq- SYS-�� '(G <br />N Contractor Address 3Q <br />T r�rs sec7G CALic# �;� ��(� <br />R Class f� <br />A Insurer SWork Comp # 0 30 0 E-- zoo cl <br />TICC Technician's Name � <br />O �U Q J�Ct e't C ti Z.- Expiration Date 01Y_ 2-s -1-3 <br />R ICC Installer's Name �Lq �L` )e SGt <br />Y1 Z _ Z,1 Expiration Date <br />Tank System work area Tank Size Date UST <br />ector,uoc <br />{i.e.87ppngsump,91I kdet�:2,eta) Chemicals Stores! Currently <br />Installed <br />T 9 r? Ttc c2.2 , Lao !� Gct 5 l i t1 <br />voA <br />N <br />K <br />P Approved _ J proved with conditions <br />L t� Disapproved <br />A (See Att ment With C !tions) <br />N Plan Reviewers Name <br />Date <br />%PPLICANT MUST PERFORM ALL V RK IN�CC RD C WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAM <br />IOAQUIN COUNTY, ENVIRONMENT L HEALTH D PA ENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />rHE PERFORMANCE OF THE WOR FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />NIORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br />THAT :N THE PERFORMANCE OF E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLO <br />)F CALIFORNIA." Y PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />,pplicant's Signature ,q <br />TO* i lLt (t l' -i Date V "51 l <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 ' <br />l! the bill! by signature and date below. (, /" <br />ICJ <br />NAME E1 I .LJP Lf i`�i 1%• 6TITLE J (t �, _PHONE # Oy — F J' S "- 945 <br />4DDRESS `1 1 V e <br />CA _ `T S -1 <br />SIGNATURE <br />EH230038 (revised 0ta/1/11) <br />. 2 <br />