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Dec 06 10 01:51 p Reliable PetroleumA 209-845-8953 p.2 <br /> ENVIRONMENTAL <br /> SAN JOAQUIN UIQ <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209)46"20 Fax: (209) 3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> HIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFF P'PIPING REPAIRJRETROFIT ❑UDC REPAIRlRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# ProjectContact&Telephone# <br /> bf'�- <br /> � Facility Name L t"����} S N (•, Phone# ---;20 9-1/ <br /> Address /t SGS S. Ha>rlcc�t C A-,tk)rvP c4 V53.30 <br /> I Crass Street <br /> T <br /> Y Ownerl0perator i pe- AqpbitLyi Phone# <br /> C Contractor lYarne E;�i�r.•}D�� v�Com► ��t,i,r_-eS fir,e • Phone#v20 <br /> T Contractor Address 1,l q 3& K ors e 5 6 i).e Ie" CA Lic# '?I?3 rj®(G, Class <br /> A Insurer STI'rT <br /> Fti<NV,> v+torkComp# tDv30fo�1 cF'"-ZUd y'' <br /> c1CC Technician's Name T G���--�- darn h ci.{-�— Expiration Date ©cf l`)—)2 <br /> R ICC Installer's N �_ <br /> 46e,(-Ir {�a{vt�,.,(".�� Expiration Date <br /> Tank Sys em work area Tank Size Chemicals Stored Current! Date UST <br /> (i.e.BT piping sump teakdetector•UDC 1rA eta) y Installed. <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Nan ie Date <br /> APPLICANT MUST PERFORM L 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 1S ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S C016PENSATIOP I LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOA0ING: 1 CERTIFY <br /> THAT IN THE PERFORMANCE C F THE WORK FOR61K�I�f,�Titla <br /> IIS PERMIT 15 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' h <br /> Appllgrd's Si ttue Date 1 t�I IJD <br /> BILLING INFORMATION: <br /> Indicate the responsible p rty to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If tie party designat W below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility for bi ling by signature and date below. <br /> j /1 acs q- 8�S-BS��p <br /> NAME t�1Gth(L' C'i Gith Servtt:2$ �d7[-TITLE_ l� � PHONE# <br /> ADDRESS j 93� f S�Ot- on-y-CW-t C A. 9S 3&i <br /> SIGNATURE DATE <br /> EH230038(revised 87!22!10) <br /> 2 <br />