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Mar 31 09 02:07p Reliable PetroleumA 209-845-8953 p.4 <br /> ENVIRONMENTAL 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 RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERM;T EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMrr TYPE BELOW: <br /> ❑ TANK RETROFIT PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT L� COLD STARTIEVR UPGRADE <br /> EPA Site# <br /> rCA <br /> Project Contact& Telephone# <br /> Facility Name <br /> Sy,.- C Phone#dG g- Fa5- &7FV <br /> AddressMAi n 51-rr-�Cross Street <br /> T <br /> Y Own -[Operator S� Phone# �0 - u <br /> C Contractor Name �u�j.e >' 9 a �-(�7 <br /> N rnYnYII�� Phone#coq- (ivy- 933 <br /> T Contractor Address I A�a 5 CA t is# �, 3 7(l,0 Class "- <br /> R Insurer a TC F /V.D <br /> A Work Camp# /3- 3 0�0 <br /> c ICC Technician's Name SSS U j51 - U Expiration Date q-d y_o9 <br /> R ICC Installer's Name S-v o- US Expiration Date <br /> + s- v.�-a 9 <br /> Tank system work area <br /> (i.e.37plpirgsump.91 laakdete=r,UDC 112.etc.) Tank Size Chemicals Stored Currently Date UST <br /> Installed <br /> A T3 T9S-I P boo G-0-561;n-2_ U�IJenai,<Jl'1 <br /> N <br /> K ' <br /> P n Approved / <br /> l_1 Approved with conditions <br /> L L_ Disapproved <br /> A (See Attachment Wrzh Conditions) <br /> N Plan Reviewers NameI�M G, <br /> NY "�/� Date_ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFfES THE FOLLOWING: 'I CERTIFY THAT FN <br /> THE PERFORMANCE OF THE WORK FOP,WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECCME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWNG: "I CERTIFY <br /> THAT IN THE PERFORMA CE OF THIE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." �1 1!4 r1 <br /> Applicants Signature V I(�` TitleICL Ij� nat �J ) <br /> BILLING INFORMATION: e <br /> Indicate the responsible party to be billed for additional EHD staff time exoended 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 date below. <br /> NAPAE TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> CH230038(revised 02120/09) DATE <br /> 1 <br />