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Dec 07..10 02143p Reliable Petrolel,mA 20A-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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> T IS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT )(COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone.4 <br /> C Facility Name In -Dtc QL Phone#.dpy_ �aS-(L -7�y <br /> Address I I DD S. AACI-In Strftj- ; 1,,jan-L C_R., Cq . 9's33�6 <br /> I Cross Street <br /> T <br /> Y Owner/Operator ha Phone# --A047- Y-IS-- -7J--V <br /> C Contractor Name I C��E ��tYU ifa t �.j V• g Phone# L/ <br /> 0 <br /> T Contractor Address f 3 ttUt-Se Silo e } 0 a lC alt CA Lic# -7Q(p Class f} <br /> A Insurer �ND work Comp# UG 6, 0,�—Z0oq <br /> T ICC Technician's Name 14ba-t- aryl har-+ Expiration Date ()ri-�L _� Z <br /> o <br /> R ICC Installer's Na p b��t �5 aYh[•l,A V<: Expiration Date U ci-2 Z -I Z_. <br /> Tank system worts areaTank Size Chemicals Stored Currently Date UST <br /> (a87 pip"sunp,91 k detatl ,UDC 12,et} Installed <br /> T P 1, L4 -f� I �Q Com. lC I �(r cc ) u yt <br /> A <br /> N <br /> K <br /> P ❑ 1,pproved ❑ Approved with conditons Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Narne 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,ENVIRO NTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWINO: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE VCRK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATIO LAWS OF CAUFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE C F THE WOR FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.- I <br /> Appkcanrs Signature I �r�l' ' Trtte U CIL �/' � Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designatad below is different than the permit applicant,e_g_ property owner, the party must acknowledge <br /> this responsibility for the billing by signature and date below. ( {- <br /> NAME 4� �t e P r01tL.,I JeYVIV5)TITLE l�lJ{�l lrll�_rn PHONE# <br /> ADDRESS 1 1 C13 b �o I-S E 5. �/C it�i� I f cl t l L t. C ( JA . q5 J 3 L✓ <br /> SIGNATURE I 1 h DATE: U I D <br /> EH230038(revised 07lMIC) <br /> 2 <br />