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Jul 2513 05:22a Reliable Petr m 20QR458953 4 <br /> RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTME JUL JUL 2 2 5 5 201"33 <br /> IENTAL <br /> SAN JOAQUIN COUNTY HEALTH DEPARTMENT <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 /> HIS°ERMiT Ek PI RES 180 DAYS FROM THE APPROVAL DATE. INDICATE�FERN17 TYPE BELOW': <br /> D TANK RETROFIT 12'(PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT C COLD START/EVR UPGRADE <br /> FEPA # Project Contact&Telephone# � (.mecf; � 5 Phone#'III i' iy% <br /> T <br /> Cross Street - <br /> Y Owner/Operator �C c�r E- Phone# � )o'i"Co 7 -7 {G <br /> o Contractor Name V"I&1Jl" W) S e CV,Le< 1-VI Phone#,9r✓19-3`f 5-j S o Cv <br /> N Contractor Address � f <br /> T ��� ✓ O ICI St'�I�c� rc� CALic# 3"lu(E� Class <br /> R Insurer <br /> A. ��.4r>)✓. clvVi� Work Comp# ;5,C36(­78' <br /> T ICCTechnician'sName Cn1LGL-rQL�L <br /> Sctiv�C, Z Expirafon Date 111 -"90- /L <br /> R ICC installers Name C�+ G� C� <br /> S Expiration Date /,_-;I <br /> Tank system work area Tank Size Chemicals Stored Curent) Date UST <br /> a.a.87 piping sL,p,Qi leak delecte,,UDC 12 erc Y <br /> Installed <br /> T C� l 10 0C, ^c SUIt v�� L, F1 )G <br /> A <br /> N <br /> K - - <br /> P L� ApprovedApproved with conditions Disapproved <br /> L (See Attach,ant VVjtt'Con itionsi <br /> A �Z/N °Ian Reviewers Name D <br /> APPLICAN-MUST PERFORM ALL WORK IN ACCORDANCE WI H SAN JOAQUIN COUNTY OROINAI S,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COJNTY,ENVIRONMENTAL HEALTH DEPARTMEN- CWNER OR LICENSED A3ENT'S SIGNATURE CERTIFIES TH=FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFCRMANCE OF TFE WDR<FOR W`ICH THIS'ERMIT IS ISSUED, SHAL_NOT EMPLOY ANY PERSON IN SUCH A MANNER.4S TC BECOME SLBJECT TO <br /> WORKER'S 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 CALIFORNIA." <br /> �- CYr a 5 <br /> Aprv,cantsSigratle Ll AtA,��. r"Wtle .�l Date ) <br /> BILLING INFORMATION* <br /> Indicate the responsible party to be billed for addi:onal EHD staff:time expanded beyord permit payment coverage per tank. If <br /> the pa.•ty designated beiow 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. r,, <br /> VAMEKt L1 Gl.�f Q>,:—tV- �c v.vt1 TITLE (�v1r(. I PHONE# ' — Li t� �� U`" <br /> ADDRESS {4 G L-e <br /> SIGNATURE � — DATE C) — 2 j 3 <br /> EH230038(evil &II/11) <br /> 2 <br />