Laserfiche WebLink
Jun 24 10 02:50p Reliable PetroleumA <br />20M45-8953 IDA <br />ENVIRONMENTAL. <br />RTMENT <br />SAN O , <br />QUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TALK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPI RES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br />TANK RETROFIT ❑ PIPING REPAIR/RETROFIT C❑ UDC REPAIRtRETROiFIT ❑ COLD STARTfEVR UPGRADE <br />F' <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />`C <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 />EPA Site # Project Contact & Telephone # yn�r F aoy (oy v -y33 <br />Facility Name N a VVI �C-PrL--'L�, t 1 C- vrah Phone a <br />Address a (- <br />3 3 0 � t,�.7 . H-�. w` � e. Ir- tL&# � <br />Cross Street <br />Owner/Operator <br />Contractor Name R <br />Contractor Address <br />Insurer .5-rA. T- G FUN D <br />IGC Technician's Name .,ua 0111 <br />ICC Instalter's Name r, ,A <br />Tank system work area <br />(l.s. 8700'ng SUMO, 91 isakde*aor, UCC 112, etc,} <br />) e r-STi_l i ea LA V <br />Phone #L-g0Ct _ 979:--9'z92 <br />SeVv� L.ea Zm�� Phone#�Uq-J y5 -�SlS(P <br />3� er►v Sir CA Lic # g� 3 �� (p Class A- <br />W%k comp #'1 ! 3 - UU3 v(o7 F -v 9 <br />SGt t�G�►G'� Expiration Date 6 LI -3 0 r / / <br />sum Expiration Date <br />Tank Size Chemicals Stored Currently Date UST <br />j Installed <br />P I- Approved Approved with conditions <br />L L ' Disapproved <br />A ��3 achrnent With Conditions) <br />N Plan Reviewers Name <br />Date H,�v <br />APPLICANT MUST PERFORM ALL WORK ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON M SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "! CERTIFY <br />THAT LI THE PERFORMANCE OF THE WORK FOR WHICH:�1iIS PERAAj7 IS ISSUED, !SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA' , r S,P ..- <br />APPikant's Sigmtum Ti89 b ii tr ' U r— Die o Le �. I <br />BILLING INFORIUTAI ION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond <br />the Marty designated Flow is different than the permit & .permit payment coverage per tank. if <br />responsibility for the billing by signature and date below, applicant e.g. property owner• the party must adcnovAedge this <br />NAME TITLE <br />PHONE # <br />ADDRESS <br />SIGNATURE <br />EH230038 (revised 02I20t09) BATE <br />1 <br />