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Jun 24 10 09:54a Reliable Petroleu 2 45-8953 p.4 <br />it . � ► , ■ l � <br />SAN JOAQUIN COUNTY <br />640 East Main Street, Stockton, California 95202 <br />Telephone: (249) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT KPIPING REPAIRfRETROFIT i r UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # p6b& vq_ f��cj 3 <br />A <br />Facility Name G _S ME Q - <br />Phone # 2 3 3 <br />i L <br />Address )330 E- �oSeYh;} v�✓tt�.4 <br />I <br />T <br />Crass Street <br />Y <br />OwnerfOperator >'evirt <br />Phone# Z <br />0c <br />Contractor Name �e�CaL71� �� p 1 esti i� Je.>' v +'cs�- t^ <br />Phone # do g!5 -'F <br />NContractor <br />T <br />Address _ CA Lic # F'9 3 -7 O (a Class 4 <br />RInsurer <br />A <br />S �c 1 � - til N t1 <br />Work Comp # -7 13 -,g U 3 U <br />T <br />ICC Technician's Nameu <br />(9 SQw'J.t-z <br />Expiration Date ()q-30-1/ <br />R <br />ICC Installer's Name Crn��° 5'a K.tA...e..Z <br />Expiration Date (} <br />Tank system work area <br />(i.e. a7 pips sump, 91 leak detector, ucc v2, etc.) <br />Tank Size Chemicals Stored Currently Date UST <br />y Installed <br />T <br />iAY1 <br />X51 u IL SQ <br />riff._aAjC`. <br />K <br />P <br />❑ Approved Approved with conditions _� Disapproved <br />L <br />A <br />(S hment With Conditions) <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS iSSUEO, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CAUFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLO'AnNG: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH! THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OFCAUFORNW' <br />^�..._ F <br />Applicant's Sign } b Eh �c� Titer ( VYI �� (—G' Jr Dees L �0 /G�Z / % <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 the billing by signature and date below. <br />NAME TITLE PHONE * <br />ADDRESS <br />SIGNATURE DATE <br />EH230038 (revised 02!20/09) <br />1 <br />