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Jun 23 14 04:29a Reliable Petrol-urn 20Q8458953 p.4 <br /> ENVIRONMENTAL HEALTH DEPART-ME'NT, <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street; Stockton, California 95202 JUN 2 3 2014 <br /> Telephone: (209) 468-3420 Fax: (209) 468-34333TA-N�/I <br /> APPLICATION FOR UNDERGROUND STORAGE WRONMENT.AL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> - <br /> THIS PERMIT EXPIRES 180]AYS FROM T.IE APPROVAL DATE INDICATE°ERMIT TYPE BE.CvY <br /> TANK RETROFIT ❑PIPING REPAIRIRETROFIT t UDC REPAIRJRETROFIT QXCOLD STARTIEVR UPGRADE <br /> F EPA Site# --Project Contact&Telephone# Ro be.0-,qoq-t00i - 3 3& <br /> � <br /> Faci.i;y Name Li �� /,n r�SQ>Ly J� Phone#005-963 -7 <br /> 1 .Address ? i�ll�`� J• 1 13�1Y� S� ,r'll t Sfi)"ictyn _�k 95zil <br /> Cross Street <br /> T --- — <br /> Y OwnerJOperatcr �t�1'1 L Phcne#—JOtJ 69 --7 <br /> C <br /> Contractor Name � " ) - -_V L>°.5 C• Phcne#,-30 <br /> T Contractor Address j(� Q Lic# Clasps <br /> A r InsureT - - Work Comp# <br /> TICC Technician's Name ;�� 1 Expiration Date 09 <br /> RICC Installer's Name -� G�In Expiration Date .Z - <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> Ie.87piamgsusp 911,. iecutUDClr2,elc.) Installed <br /> t <br /> T i <br /> A <br /> N --- -- <br /> K <br /> t <br /> p Approved pproved with conditions 1i Disapproved <br /> L { e ttachment With Conditions) I <br /> IN <br /> N Plan Reviewers Name � G Date1 101 <br /> IV 41 <br /> PPLICAM MUST PERFORM ALL'WORK IN ACCORDANCE WITH SAN JOA.QUIN NTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> IOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGtJATURE CERTIFIES THE FOLLOAING '7 CERTIFY THAT WI <br /> HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER.AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTCR'S HIRING OR SUBCONTRACTING SIGNA"UR-CERTIFIES THE FOLLOWING. 'I CERTIFY <br /> THAT IN TFE PERFORMANCE OF THE WORK FOR CH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAJNS <br /> OF CALIFORNIA" <br /> fthatPPli2nt'sSignalLire J <br /> BILLING INFORMATION: <br /> ndicate the responsible party to be belled for additional El staff time expended beyond permit payment Coverage per tank If <br /> the party designated below is different than the permit aopficant. e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by sign fore and date beloyw. /� -}-� �. �,`,�^ /''� z �j� <br /> NAME ` t„ 2. QiV1 )AI/l TITLE ( oyi, I r aC_f (J! PHONE# �q/- Olq-q-3✓ T <br /> ADDRESS <br /> SIGNATI �1 -----__DATE_. Q+ <br /> URE J <br /> EH230036(revised 1;11) <br /> 2 <br />