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Feb 15 11 05;07p <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />O <br />R <br />T <br />A <br />N <br />K. <br />P <br />L <br />A <br />N <br />Reliable Petroleu L 20,&k45-8953 p.4 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 Fast 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 PERMrr EXPFRE5180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br />0 TANK RETR t*IFIL G REPAWME€ROFIT Q UDC REPAIRfREMFIT 0 COLD STARTIEV11 UPGRADE <br />EPA Site # Project Contact & Telephone # <br />tL�.e�Ol.tKFacility Name j 1Son wtI C.)iey a Phone# ��'� <br />Address I Sv <br />CA . <br />Cross Street <br />Owner/Operatori� E �, <br />Contractor Name <br />ContractorAddress f 19':?)p Hod^ <br />IRSUrerF <br />LCC Technician's a <br />ICC Installer's Narm <br />Tank system work area <br />(Le 87 pgmg simtp. 9111138kor, UDC 12. etc.) <br />Plan Reviewers <br />! <br />...Ntehr0 Phone#�Oq- 9°Ja-r33�jt <br />SE✓rvi It- =-)I Z'. Phone#o09— 00t/5= ?SW <br />SCS h o e ! CA Ue #`6 3 7 U Cv Class <br />_ Work Comp # O� 3G' C� <br />Js' wi (..V i� Eviration Date <br />�a C,�• _- Expiration Date 12.- <br />Tank Size Chemicals Stored Currently Date UST <br />Installed <br />conditions ❑ Disapproved <br />Conditions) �% l <br />Date li <br />APPLICANT MUST PERFORM A WOR ACCOR E WITH SAN JOAQU IN COUNTY NANCES STATE LAWS AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONM TAL LTH DE T. OWNER OR LICENSED S SIGNATURE CERTIFIES THE FOLL0IAAAIG: "1 CERTIFY THAT IN <br />THE PERFORMANCE COCE OF THEW FOR WHICH R PERMIT is ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS 70 BECOME SUBJECT <br />TO VYORKERS COMPENSATION WS OFCALIFOR " CONTRACTORS HIRING OR SUBCOFITRA NY P SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY <br />THAT IN THE PERFORMANCE THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EIyPLOY PERSONS TURECT RT WORKERS COMPENSATION LAWS <br />OF CALIFORNIA <br />Appkant7s s1 re 0 47 <br />Indicate the responsibleto be bitfed for additional EHD staff time <br />Tank. If the party design) below is different titan the nd� beyond permit paymerrt cxO <br />erage per <br />this responsibility for the bill by signature and date below. >t i a -g property tee' ft party must acknowledge <br />EH23DO38 (revised 07122110) <br />illillillillilli�ilill 111111 <br />r <br />t 1 h ► / t <br />2 <br />_.91%03 <br />