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Aug, 16 12 12:29p, Reliable PetroleumA 209-845-8953 p.4 <br /> E% IRONMENTAL 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 /> THIS DERMr EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW, <br /> 0 TANK RETRO IIT)(PIPING REPAIR(RETROFIT OUDC REPAIRfRETROFIT 0 COLD START/EVR UPGRADE <br /> A <br /> F EPA Site# <br /> Project Contact&Telephone# <br /> C Fadlity Name s2-&QZPhone 31v <br /> I —_- --- - - 7 <br /> L Address VKD Pax-%e�A'2nq —FraL 0 T53 <br /> ryI <br /> T Cross Street <br /> Y Owner/Operator <br /> 0 Contractor Name mhc' Phone# <br /> N - 6* <br /> TContractor Adds liq ko-e CA Lic# <br /> R 3 20 CP claw A <br /> A Insurer S Work -7 <br /> C Comp A 00 3 <br /> ICC Technician's Na'ne <br /> a Expiration Date <br /> R 1-CC Installer's Name! C—..;, <br /> Expiration Date <br /> Tanks m work area Date UST <br /> (i.e.87pipini;sump,91 §8kdWec(*,,UD-_W2,ey_,) Tank Size Chemicals Stared Currently Installed <br /> T <br /> A <br /> N <br /> K <br /> P D Al Iprovedr-, <br /> proved with conditions Disapproved <br /> A (See Attachment With Conditions) <br /> N <br /> Plan Reviewers Nami <br /> PPLICAN7. MUST PERFORM ALL NORK IN ACCORDANCE AWH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAOUIN COUNTY,ENVIRONMEN'AL HEALTH DEPARTMENT,(MINER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWAG. "I CERTIFY THAT JN <br /> THE PERFORMANCE OF THE VVCF K FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUEJECT TO <br /> WORKERS COMPENSATION LA'A)*OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> TKAT IN THE PERFORMANCE OF ME WORK FqR WHICH THIS PERM-T IS ISSUED.J SHALL EMPLOY PERSONS SUBJECT TO WOR <br /> OF CALIFORNIA.' K-ERS COMPENSATION LAWS <br /> Applicant's Signatae pr- <br /> _6e - Date <br /> BILLING INFORMATION: <br /> Indicate the responsible par:y to be billed for additional EHD staff time expanded beyond permit payment coverage per tank. If <br /> the party designated belm i is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing signature and date below. <br /> NAME tAlf <br /> PHONE* <br /> ADDRESS <br /> u. q6rs-es <br /> (A . 9All <br /> SIGNATURE <br /> DATE QVIA112— <br /> EH230=(reviseW0811,11 I) <br /> 2 <br />