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Jul 25 13 05:27a Reliable Petrol- -1 21 458953 p.20 <br /> HECEiVED <br /> ENVIRONMENTAL HEALTH DEPARTMENTJUL 25 2013 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> 600 East Mair Street, Stockton, California 95202 HEALTH DEPARTMENT <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 1SC DAYS FRDM THE AP=ROVAL DATE. INDICA-F�PERMJT TYPE BELOW: <br /> TANK RETROFIT n�PIPING REPAIR/RETROFIT 7 UDC REPAIRIRETROFIT ❑COLD STARVEVR UPGRADE <br /> F EPA Site# Project Co-tact&Telephone# 90q <br /> P-0 a04 <br /> A -- <br /> G Facility Name Uk:o It t A &0.5 Phone# <br /> 1Adores 12 L'I t C r- ✓Jl a�� S ►re Stn A1C r4 <br /> I Cross Street <br /> T <br /> Y Owner./Operator �Cc�e £ Phone)ll q-V(y,? --7 7 1(gy41 <br /> Contractor Name �'�1ia}�12 PG�r t1�+a �n1 S E�V'�c 5 S-N Pho #�t��-S`I S-C'S Cv <br /> N Contractor Address �� S 1,, CA Lic# (j 11 Class <br /> T I E 9 c' 2_d A <br /> R Insure( <br /> A j�.'•�'�")~ ��tv�;� ort<Come# .� -C•C5'G'(C"7� <br /> T ICC Technician's Name C''��a- Ce�n Sc�> C,Iti e Z Expiration Date of -00- j(_ <br /> Dnstaer's ame <br /> R ICC Installer's N ���c�-(�C�.A.k• � �. t..c Expiration Dare <br /> Tank system work area Tank Size Ch icals Stored Currently Date UST <br /> (..e.E7 ppnp s�,P,s1 leak deteeMr,UDC 1 c.eua Installed <br /> T :Ct G l� )C� CC`O Lk I L K— <br /> A <br /> IN - <br /> K <br /> P J Approved EApp 'led with conditions Disapproved <br /> L {See Attac ment With Conditions) <br /> A <br /> N <br /> Plan Reviewers Name j Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH /SA JOAOUIv COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OP SAN <br /> .CAOUIN COUNTY,ENVIRONMEN—AL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S S,GNATUR=CERTIFIES THE FOLLDAING: •1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS I$SUED,I St V+U_NOT=M?LOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACfCR'S HIRING OR SUBCONTRAC-ING SIGNATURE CERTIFIES THE FOLLOw1NG: "I CERTIFY <br /> 7-IAT IN7H=PERFORMANCE CP THE WORK FOR WHICH THISYERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> Appli®nTs Signalure �J V l"Qit{e 'C+�fii Dale <br /> � BILLING INFORMATION: <br /> Indicate the responsible party to be billed fql`additional EHD staff time expended beyond permit payment Coverage per tank. If <br /> :he party designated below is different an the permit applicant e.g property owner, the party must acknowledge this <br /> responsioillty for the billing by signature a tate below. <br /> KC <br /> C O o r <br /> NAME KC`\ i�AF T r()�t�• �1 TTIT-E�C+�� Y(.+- - tf 1 PHONE# (1 �- Li j�C` <br /> ADDRESS t 1 L 'D O P-6 ti's ��y-e K v��� �C) �� .� Chi g S✓�` l _ <br /> SIGNATURE q hk�v,ilDATE C-) <br /> EH230038(rev, '11/11) <br /> / 2 <br />