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Sep 16 08 02:18p 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 BELOW. <br /> 'TANK RETROFIT _IP'PING REPAIR/RETROFIT UDC REPAIRJRETRCFIT UCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> AS r� <br /> C Facility Name fq ClI n 5"-)-r cC_ �- q L() Phone#�G 7�= <br /> Address <br /> TCross Street <br /> Y OwnerlOperator �e5 �� 1C Phone# � <br /> C Contractor Name Ov-e.c i' Phone#-,f)0,7- <br /> Contractor Add <br /> N onracor ress 3 S � C) (D Class <br /> T ��-� �fC+�1C�LYt �-1"G►'� jT. CALic# 3 <br /> R Insurer <br /> A PJC �.�v� �'o ti� rv�C I•�•�4...L. Work Come# A/ 14 <br /> T ICC Technician's Certification Number 5 .L c 1 S i — t,lT Expiration Date g1,--') '?1017 <br /> oICC Installer's Certification Number F <br /> R :5aExpiration Date —'/0�' o � <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T T-3 Go, II'nc- uk j/—k10u;;l <br /> A <br /> N <br /> K <br /> P UApproved Approved with conditions Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> �a <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUfN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGJLATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S 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 IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMA E OF THE WORK FOR WHICH T IS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CAU FORNIA" J <br /> Applicants Signature 'l <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 9k <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 12/31107) <br /> 1 <br />