Laserfiche WebLink
Jan 14 11 09:57a Reliable Petroleu 20 -845-8953 p.4 <br /> ENVIRIDN MENTAL HEALTH um""IEPARTMENT <br /> SANJOAQUIN COUNTY <br /> 640 East Main Street,Stockton,California 95202 <br /> Telephone: (209)46&3420 Fal:{204} 3.433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> IS PERMIT EXPIRES 18+0 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFI'4.PIPING REPAHMETPOM OUDCREPAMIRETROFff <br /> 0 COW START E <br /> A EPA site# P Contact Telephone �� <br /> C Facility Name A co Phone# <br /> L Address 3 SU Pom bo A i Zo on <br /> lL <br /> 1 Cross Street <br /> T <br /> Y Own xr perator 5'4 ytc <br /> O Contractor Name 11Q bI� t l e�le.v.rv� Sc- GK'S T h C e Phone# <br /> T Contractor Addrem i/730 Her,,e sh a e d� d CA t is# Yb'3 70(v class <br /> A Insurer S1 Aic_ I FIS-ti D Work Comp# 4 4 407'? 7:;V0 <br /> T' ICC Technician's N 6e Pob-ert y-V1 k&r* Expiration Date <br /> R ICC IRstatier's Nam' be-r 4- aYN�1cLr-i-- <br /> Expiratiola Date <br /> Tank sys work area Tank Sate Date LIST <br /> 0-ar port s I leak ter.LOC Ira,ems} Chemicals Stored <br /> Installed <br /> T [.. <br /> A <br /> N <br /> K <br /> P ® <br /> L roApproved with conditions 0 Disapproved <br /> A (See Attachment Vift Conditions) <br /> N Plan Reviewers Nan ieDate 1 <br /> APPLICANT MUST WO <br /> PERFORM A'L RK IN ACCORDANCE <br /> JOAQUIN C�NTY, WITH SAN JOAQI#N COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> ENVIRONM NTAL HEALTH DEPARTMEN OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FMOWING "I CERTIFY THAT <br /> IN <br /> THE PERFORMANCE OF THE RK FOR WHCH THIS PERMIT IS ISSUED,I SHALL NOT ANY PERSON IN SUCH A MANNER AS TO BE_RTiF THAT IN <br /> TO WORKER'S CO TIO LAWS OF CALIFORNIA." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. "I CERECT <br /> THAT LI THE PERIA." THE VYORK FQR WHIG THIS PERMIT IS ISSUED,l SHALL�APLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAVVS <br /> TIFy <br /> TH CALIFORNIA' o f <br /> Awk.nrsS' pates <br /> BILLING INFORMATION: <br /> Indicate the responsible My to be billed for additional EHD staff time expended beyond permit payment Coverage per <br /> tank. If the party designab d below is different than the permit applicant; e.g.property owner,the party must arm <br /> owledge <br /> this n onsi}bitityif�o,Ir the ' ing by signature and date below. / y� �% <br /> NAME !4 .XJ` ti 2 I TITLE l�(1jvi(�G( I _PHONE � ?q—J tI�� <br /> ADDRESSI UU <br /> SIGNATUR €3ATTIErJh.� I f/ <br /> EK230038(revised 0 10) <br /> 2 <br />