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Jan 24 11 09:10a Reliable PetroleumA 209-845-8953 p,4 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQvIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PEFMIT <br /> HIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERRUIT TYPE BELOW: <br /> OTANKRETROM U PIPING REPAIR/RETROFIT O UDC REPAIRIRETROFfT DCOLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# et'-E a r',,7Aa t'-f- (GO t(-93.3(� <br /> C Facility Name 'lj Street JcC`(} Phone# (a 7 F <br /> I <br /> L Address I ic�o S, 1�1a�n s ire - lan�� cA _ 9s'33 <br /> I Cross Street <br /> T <br /> Y Owner/Operator X'u- + S)i r I Phone# �Q y' - �� -(p 78 <br /> o Contractor Name e'+ aril h� — Phone#��� vs- (fse <br /> T Contractor Address CA Lic# "3-70k — Ctass <br /> RInsurer +A+ Work Comp#00 (p-V-�Gq <br /> A <br /> T ICC Technician's Name �,( �;� ^� r Expiration Date <br /> a ICC Installer's Narr e �� Y�I l Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Dane UST <br /> (i.e.87 poing s rnp. teak baa.UDC 112,etc) {� Installed <br /> A <br /> N <br /> K <br /> P I] Approved Y/Approved with conditions Q Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Na e Date N" <br /> APPLICANT MUST PERFORM kLL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVRONI AENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: h CERTIFY THAT IN <br /> THE PERFORMANCE OF THE hORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATIC N LAWS OF CAUFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT I N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Appicant's Signature I / h L�l� TM. <br /> BILLING INFORMATION' <br /> Indicate the responsible oarty to be billed for additional EHD staff time expended beyond pen-nit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner,the party must acknowledge <br /> this responsibility for the ill by slignature and date below. J <br /> NAME � Li (�I CI YS'! Y�L E 0M+V(LC-hr PHONE#0oq- � V S 'S SS 0 <br /> ADDRESS L SSS► [t7� U CcL (� Lac 3Cp <br /> SIGNATURE DATE C l I a y II <br /> T"T <br /> EH230038(revised 0712211 <br /> 2 <br />