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Jan 08 09 12:41p Reliable Petroleum 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 PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOIW <br /> n <br /> jTANK RETROF17 ]PIPING REPAIRIRETROFIT ❑UDC REFAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site# 77FProiject Contact&Telephone# <br /> A �ccr - orY1h6v}` <br /> C Facility Name f— ) Phone# t;Q <br /> L Address I J Ma` <br /> r-e A) t:t- CA. 9s3.3 . <br /> ICross Street <br /> T <br /> Y Owner/Operator ��JS �'�� Phone#' c �'�L 5--(G'1 C( <br /> C Contractor Name. > � Phone <br /> r qL c <br /> N <br /> T Contractor Address j�1 r C <br /> , It l -�- CA Lic# a r� Class <br /> R Insurer <br /> A BC I'l vi Y-U}1 m til— u CJ Work Comp# 14 <br /> D ICC Technician's Certification Number <br /> T Sz.Sp 45�- �, �'" Expiration Date q � p <br /> R ICC Installer's Certification Number <br /> Jrz-� � L) — Ll,� Expiration Date � i?� �g <br /> ::;T�ank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T L7 �l i E,fYI J i 7 r <br /> A <br /> N <br /> K <br /> P UApproved I"'Apprcved with conditions ]Disapproved <br /> 1- (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name �� /V14-tDate_ <br /> /i Flo 9 <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 CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA_" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOVNNG: "I CERTIFY <br /> THAT 1N THE PERFORMANCE OF THE WORK F.4R WHICH THIS PERMIT 1S ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." 1 <br /> Applicants Signature L-)7 i�� � _. 2y Tdle ��l (i�U(; '��I Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended 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 /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EF112WO38(revised 12/31/07) <br /> i <br />