Laserfiche WebLink
May 19 10 09:36a Reliable Petroleum <br />209;L45-8953 p.4 <br />6 A 40 <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 RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW, <br />D TANK RETROFIT El PIPING REPAIRIRETROFIT 9 UDC REPAIPJRETROFIT 11 COLD STARTIEVIR UPGRADE <br />L <br />F EPA Site # <br />A Project Contact P. Taiankn— 46 . -A <br />C Facirity ]Name Telephone n e # <br />I <br />L Address Ll Phone <br />)nq <br />T Cross Street 4,CL+-14rqP CA- q 4;—n 1 -4 n <br />Y Owner/OperatorIJ I Phone <br />0 Contractor Name 6/ -1 � <br />N -f- ely, kh' LA&Imrk Phone# CC/ 9 <br />7 Contractor Address < q j <br />R rcuV�_ -S;F c <br />A I insurer CA Li # �7 0 Class <br />C ICC Technician's Work el, -- .y - <br />T ician's Name <br />0 7Y 2ZO <br />R ICC installer's Name Expiration DateOtt 3GI—FI <br />Tank system work area Expiration Date <br />r1q. 87 piping swo. 91 lealtdatwor, ucc in. etc,) Tank Size Chemicals Stored Currently Date LIST <br />T Installed <br />A C, LLI-L]Ck,16W <br />IN <br />K <br />PD Approved <br />L .19, Approved with conditions r Disapproved <br />A (S Attachment N Plan Reviewers Name With COnditicns) <br />Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS, AND RULES AND REGULATIONS OF SAA, <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT <br />;N <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT Is ISSUED, I $HALL NOT EMPLOY ANY PERSON IN SUCH A MANLNLEIR AS TO BECOME SUBJECT <br />OF CALIFORNIA." VA <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY <br />THAT IN THE PERFORMANCE or- THE WORK FOR WHICH THIS PERMI 71 IS ISSUED, I SHALL EMPLOY PERSONS <br />SUBJECT TO WORKER'S COMPENSATION LAWS <br />Applicant's signahjre <br />Flue 0 <br />CM r i Dale Is <br />-%Ivw% I lur`4 - <br />Indicate the responsible party to be billed for additional EHL? staff time expended beyond permit Payment coverage per tank. If <br />the party designated below is different than the Permit applicant, e_g_ pr <br />responsibility for the billing by signature and date below. Property owner, the party must acknowledge this <br />NAME <br />TITLE —PHONE <br />SIGNATURE <br />EH230038 (revised 02j20109) DATE <br />