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Dec 08. 10 02:12p Reliable Petrol--•nA 2nQ-845-8953 p.13 <br /> . r <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SALT JOAQU N 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 PERMIT <br /> fS PERUIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW- <br /> D TANK REMOFR ❑PIPING REPAIR)RETROFIT 0 UDC REPAIRIRETROFIT ,COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A b r+- X309-(�o y-93 3 <br /> pp <br /> C Facility Name JIB n S� � Q6 Phone#aU y_ Y.;�P S-(c-7 9 V <br /> 1Address 1 10 0 S r J' cx+n Sfir-e e - /J7 Ct l CA CA 953 3 <br /> T <br /> Cross Street <br /> Y Owner/Operator K� ! S��✓jam Phone it 90'1— F-2-5-- 6-7.9V <br /> 0 Contractor Name r j t�o ILLI v;r�s Phone# <br /> T Contractor Address Il q30 NOf5eSh0 e 120 l palcdE�Q'(, CALic# -7LI) Class,¢ <br /> R Insurer <br /> A STAT e'�Nb work comp# 0 <br /> C v(o7S--Zao9 <br /> T ICC Technician's Name 120 be-k'-}- cLYYl k CLt'-+- Expiration Date Q�-j _j Z <br /> R ICC Installer's NameR p i �2t1 Expiration Date <br /> Tank sysWm work area Tank Size Chemicals Stored Currently Date UST <br /> (t-e.870;*V amp.91 deoe�r.UXlrzeml y Installed <br /> T CL�1 .arL i LOCA-J4 VJl _ <br /> N Cr Li ,a ov (L- (tea sohnf, . <br /> K <br /> P ❑ A pproved Approved with conditions <br /> ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Nam A,) tJ('�-I P-L-\ Date <br /> APPUCANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONME NTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWINaL -1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A ItiMNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPESVSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLAWING: -1 CERTIFY <br /> THAT IN THE PERFORMANCE O THE WOR FOR NMICH THIS PERW fS fSSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMpENSATrON LAWS <br /> OF CALIFORNW" <br /> AppricmftSkpahre TideVdL� - & Date 1fJ 0-7 0 <br /> BILLING INFORMATION: <br /> Indicate the responsible pe rly to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party densignated below is different than the permit applicant, e.g_ property owner,the party must acknowledge <br /> Ibis responsibility far the bill by signature and date below. <br /> NA �l l�, l��` - p /, <br /> ME ►\C 1`I 1 e P rD�� , SeYV;c�STITLE a' �l.Cj'y) PHONE# <br /> ADDRESS a v s"5 e 5 Cao 0.G' Arc 1'T U c-A: Cct . <br /> 51GNAT JRE 1 DATE l a-� 1►n <br /> EH230038(revised 07!22110) <br /> 2 <br />