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Aug 12 09 11:20a Reliable PetroleumA 209-845-8953 p.4 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SANJOAQUINCOUNTY <br /> 600 East Main Street,Stoddon,California 95202 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERW7 TYPE BELOW. <br /> ❑ TANK RETROFIT d PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# <br /> A Project Contact&Telephone# 6644343 <br /> - <br /> C Facility Name a 1ltw �ct S N .� o c Ph^one# �9 LIS'�) ?5- -0 <br /> Address <br /> I Cross Street <br /> T <br /> Y Ca+rrterlOperat!, �� - Phone# ,90 9- t/ S <br /> o Contractor Name �. Phone# (� <br /> N Contractor Address <br /> T `�� 1 �'j1rG�t'�ls • :�l'dr. ..5'-$z. CALX# �'a��'7b (0 Glass .� <br /> R <br /> A Insurer .` j' p i..GAS Work Comp# ' /3- dl Ct Q`7t"- d <br /> ICC Technician's Name pb£rLITp JCo <br /> o d 53 S,�-.S'�18- Expiration Date �•= <br /> R ICC Installer's Nameb-'ty+ a 5a X54 -- Yf Expiration Date Or <br /> a -le) <br /> Tank system work areaTank Size Chemicals Stored Currey Date UST <br /> (Le.87 pipet swpa,91 leek deleaa;UDC U2,eir—) lY Installed <br /> T ALlr!?0 Ga561ivze <br /> K <br /> P C' Approved with conditions Disapproved <br /> L �Approved <br /> t With Conditions) <br /> A <br /> N Pian Reviewers Name --,�,��Ita , <br /> paw <br /> APPLICANT(MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SALMI <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR W141CH THIS PERMIT IS ISSUED,I MALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKERS COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 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 /> OF CAUFORNIA' <br /> ApplicariYs Sloataxe i 011e a Li Date <br /> BILLING INFORMATION_ <br /> Indicate the responsible party to be bitted 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 elate below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230MB(revised OW") <br /> I <br />