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Dec 07 10 01:48p <br />Reliable PetroleumA <br />1 0 <br />209-845-8953 p.9 <br />1 <br />tONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN ! <br />it Fast Main Streelt, <br />Telephone:l* I(209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT ORPIPING REPAIR <br />[S�PERMIT EXP RES 180 DAYS FROM THE APPROVAL DATE. INDJCATE PERMr r TYPE BELOW; <br />0 TANK RETROFI IPING REPAIWRETROFIT 0 UDCREPAIRMETROFIT 0 CIDM --rART/;:%M 1 eel--0Anc <br />F <br />A <br />EPA Site # <br />Project Contact &Telephone # % ��� g� I'h �� d li �G9-�oU`f -9 <br />c <br />Facility Name C <br />5 I� Pa T- Phone �� <i' 8r� S- 0332 <br />L <br />Address ( 330 <br />OseM�ti-FC AVelYI L, -.t:_ 0,Jq CA -?5- 3 <br />T <br />Cross street <br />Y <br />Owner/operator <br />ct V^ <br />tr rf-1ff-1 V- <br />Phone # '90 q-4S�D3 38 Z <br />ContractorName <br />lV <br />t L J �t✓� .l�i'1G. <br />Phone c2() <br />#qo <br />I <br />T <br />Contractor Address J j q 3 O i'$>°$%D� f�U��( (,� Gl �c CA Lic# 3-7G (F, Class <br />R <br />A <br />Insurer S"��4T <br />FuilO-77.> I Work Comp # 003040V-2,06cl <br />T <br />ICC Technician's <br />me b e -r- - CL rki Expiration Date 0 tf -/tl -I 2 <br />R <br />ICC Installer's N <br />�}��, '/ ' b�.�"� f=.XhYJl1 i`1 U.Y � Expiration Date 0 Gj <br />Tank Sys <br />(.e.87pipir�s=P. <br />ern work area <br />leakdarecw. uoc v2, e4e J Tank Size <br />Chemicals Stored CunerlUy Date UST <br />Installed <br />T <br />r� <br />1 5t -P <br />l a YvL lAVl <br />�')(T 1I 1 LTC h g <br />A <br />N <br />K <br />P <br />proms Approved with conditions ❑ Disapproved <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Narr <br />a l'V ` AI PI Date � <br />APPLICANT MUST PERFORM A L WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONM NTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT`S SIGNATURE CERTIFIES THE FOLLOWING; -J CERTIFY THAT <br />THE PERFORMANCE OF THE <br />TO WORKER'S COMPF_NSATTO <br />THAT IN THE PERFORMANCE <br />IN <br />FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />LAWS OF CALIFORNJA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CER ECT <br />IFY <br />OF CALIFORNIA' <br />THE WORK FOR IGH TH IS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />AppkanPs Sianature6"Li <br />y} 1.� <br />V 1, ) 01xIe -W / —�L --1-) r7 —1 %'\ <br />rLLING INFORMATJON: <br />Indicate the responsible party to be biles for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designatiid below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility forthe bil ing by signature and date below. <br />NAME PIA'09b 9b f- - ..-I ..mac . TITIN_(.4n <br />SIGNATUF <br />EH230038 <br />07P22M 0) <br />kh; r5 r--5 l c,, <br />V, <br />/ J- -()-7 -I <br />W- <br />