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Sep 03 09 04:00p Reliable Petroleum 209-845-8953 p.4 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOA+QUIN 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 9PIPING REPAIRIRETROFIT ❑ UDC REPAIRlRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> AF EPA Site# Project Contact&Telephone <br /> C Facility Name00AAyltr C-101Io 4r 44 IV FtkA"e Phone#�}9-&`&Z _ �Z <br /> Address <br /> TCross Street <br /> Y <br /> o Owner/Operator ytI I - Phone -9-64,2-O rs- <br /> Contractor Name <br /> o 12,C.It a. } pe-+`0I t.t,1r•.vl <Se►�v:�,e,a-..1�.n�. Phone# �- <br /> T Contractor Address S-ZA -T-rU'n _S* _ CA Lic# �3 a 7 U 0 Class <br /> RInsurer ff <br /> A SJ A-lt� F411't WorkGomp# 0U,3G10� �_ZGG <br /> T ICC Technician's Name C <br /> O x_ Expiration Date ('41-3o -/U <br /> R ICC Installer's Name � Expiration Date .S-/!q <br /> Tank system work area s�ITank Size Chemicals Stored Current) Date UST <br /> n.ep.e�ply sump, �defector,uoc v2,etc.) y Installed <br /> T �7 -7 1.1 n&- L d + �v� CSS 41..5.0 6 0,0- <br /> A <br /> N <br /> K <br /> L ❑ Approved Approved with conditions C Disapproved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> Date v <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 IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFOR41A." �-� <br /> ApplianPsSignattxe .d'E / L`ta,/Title . 1 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 /> EH230038(revised 02/20109) DATE <br /> 1. <br />