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Apr 02 12 11:51 a Reliable Petroleu 209-845-8953 p.41 6 . a <br />1=1 <br />ONNIENTAL 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 />HIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE 6ELOW; <br />0 TANK RETROFI C PIPING REPAIR/RETROFIT C1 UDC REIPAIRMETROFrr Q�COLD STARTIEVR UPt3RADl= <br />AI <br />EPA Site # <br />Project Contact & Telephone # Lu ado -h. -Pe Suy a4e- Ca,,Y_ 934.3 <br />1Address <br />Facility Name G / `' Pu I <br />Phone # 2G y- F2-,3-- 03 3 2 <br />L <br />f 33(? <br />1 <br />T <br />Cross Street <br />Y <br />Owner/Operator I'Le <br />Vi ;� f f u t•- <br />Phone # Z.0 9- S S- 03 3 _Z <br />c <br />o <br />Contractor Name OO <br />KC' i t <br />,01f4{m 5ervile,5, Z�qC. <br />Phone #a-)l}�j-�'Y�- 5' <br />Nr <br />Contractor Address 11,1"30 <br />, . <br />CA Lc#0 Class . <br />RInsurer <br />A <br />t Y <br />�i a k_<< <br />Work Comp # 00 3C 7,F- U d 17 <br />T <br />ICC Technician's Name <br />6-3KCL cLl t <br />Std I 1 <br />Expiration Date 0 V -2 3- <br />R <br />ICC Installers Name <br />,- « t n l 4 <br />Sa.PA Cwt Z <br />Expiration Date 12 -- <br />2r -Tank <br />Tank systemwork <br />(i.e 87 piping sump. 911ie <br />area <br />detectq•, UDC 112, ea; <br />Tank <br />Tank Size <br />Chemicals Stored Currently Date UST <br />T <br />A <br />N <br />K <br />P RA <br />L <br />A <br />N Plan Reviewers Nam <br />Approved with Conditions J Disapproved <br />(See Attachment Wdh Conditions) <br />Date Z <br />PLiCANT MUST PERFORM ALL RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, SZ -ATE LAWS, AND RULES AND REGULATIONS OF SAN <br />4QUIN COUNTY, ENVIRONMENT HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFlES THE FOL 01MNG; "I CERTIFY THAT IN <br />PERFORMANCE OF THE WORK OR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />IRKER'S COMPENSATION LAWS OF CALIFORNIA-' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: N CERTIFY <br />aT IN THE PERFORMANCE OF THE WORK FOR VA41CH THIS PERMrT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />CALIFORNIA." <br />illcant's Signature �' -� "fUec'ii fir GY"� <br />�fP 6q <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 s different than the permit applicant, e.g, property owner, the party must acknowledge this <br />responsibility for the billing by 'gnature and date below. 1 !1 r <br />NAME 1 At/lrE OI b 7 •� V. Z C, TITLE_ t L►blf� 1 p— PHONE # .7 [� 7 ' J V 940 <br />ADDRESS I q 3 C� Y S C C- !� �f `{• C. �.- ���CF r <br />SIGNATURE X <br />DATE &Lf -4 f Z- <br />EH230038 (revised 08/1111) <br />