Laserfiche WebLink
Jan 14 11 10:01a Reliable Petroleu 209-845-8953 p.13 <br /> ENVIFLPONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600.East Main Street,Stockton,California 95202 <br /> Telephone: (249) 3420 Fax: (209) 433 <br /> APPLICATION FOR UNDERGROUNDSTORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> IS PERMIT EXPIRES IN DAYS FROM THEAPPROVAL DATE. INDICATE PERMIT TYPE BELOW.. <br /> 0 TANK RETROFI I7 ANPM REPA ROFIT 0UMliRMOFff 0 COLD STARTIEVR WaGiIiiii <br /> A EPA Site# I Prot Contact&Telephone# [ _ <br /> C Facility Name 19-�tl F f3 30 <br /> i � (.� i�Yrt F'i"3'1 <br /> LAdd3 J C3 z 1 Phone# L q-930 -x`77 <br /> I Cross Street <br /> T <br /> Y o h-act am <br /> Con#racbNam <br /> I k�c;l Jetf- 5- 1L Phan#30IT-F30—?r) <br /> or Namel irlbif_ �}!t,f C 11im scrvi GY's 3:)-,c . Phone <br /> T Contractor AddressI i1730 HPr,,eSIZ i�!.d I Q CA Lie# 7U C,^ Class <br /> R <br /> Insurer S tk tC I F`u•v i7 Work Comp# 0 el <br /> C 3 C '1go <br /> ,>Q q <br /> T ICC Technician's N Mme a�n I,-t <br /> o Expiration Date 0 L/ /�/"/a <br /> R ICC Installers N i 12Ube��- ctl'n��ctl�t- <br /> Expiration Date D 9- -4,:;L-1,Z <br /> Tank m work area <br /> CA 870*9 wane laakGenector,uoc ilz aua.l Tank Size Chemicals Stored Currently Date UST <br /> Installed <br /> T <br /> A L11 jlC' <br /> N <br /> K <br /> LEl i ❑ Approved mth conditions ❑ Disapproved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers N <br /> Date <br /> APPLICANT MUST PERFORM L WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> THEJOAQUINPER COUNTY,ENVIRON AL HEALTH DEPARTMENT.OWNER OR LICENSED AGEM"S SIGNATURE CERTIFIES THE FOLLOWING: "!CERTIFY THAT!N <br /> THE PERFORMANCE THE RK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOYANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO THAT <br /> THE P RFORM SATS LAWS OF CALIFORNIA." CONTRACT01i HIRING OR SUBCOIdrR=ING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMA O.THE WORK WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" I <br /> 13 <br /> BILLING INFORMATION: <br /> Indicate the responsible p rty to be billed for additional EHD staff time expendednd <br /> tank If the party design Is nt than Otte permito paY> tcoverage per <br /> this resp bitlty(tf_�oEEr the 'I n9 by signature and date below. e.g.egedY ` 'the party must <br /> � 10 e <br /> NAME TIl'LEPIRONE <br /> _ <br /> AWREss <br /> a <br /> SIGNATU <' DATE V P '. <br /> EH230038 <br /> (revised o 2tiTo) <br /> 2 <br />