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ENVIRONMENTAL HEALTH DEPART ' NT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 952 <br /> Telephone: (209) 468-3420 Fax: (209) 468- 33 <br /> A LICATION FOR UNDERGROUND STORAGE TANK RETR IT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDIC E PERMIT TYPE BELOW: <br /> TAN ETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/ TROFIT 9 COLD START E <br /> F EPA Site Project Contact&Te phone# <br /> A <br /> C Facility Nam Penske Truck Leasing Phone# <br /> I Address 3663 Petersen Rd Stockton 95215 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> C Contractor Name HMC - enderson Maintenance Co pany Phone# (209)467-7573 <br /> N ,Contractor Address PO Box 1325 - StocktonCA 9 213 CA Lic# <br /> T 856771 Class D21 / D40 <br /> A Insurer Redwoo ire & Casualty I surance Co work Comp# 4404008536081 <br /> T ICC Technician's Name Carl Wayne enderson 5252923-UT Expiration Date 8/10/10 <br /> R ICC Installer's Name <br /> N/A Expiration Date <br /> Tank system work area ank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P _l Approved n Approved with�citions ❑ Disapproved <br /> L (See Attachment With o itions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL ALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNAT E CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK F R WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PE SON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAW OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING S NATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF TH WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSO SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature `' Title Contractor D 6/15/09 <br /> BILLING INFORMATION: <br /> Indicate the responsible p rty to be billed for additional EHD staff time expended beyond permit p ment coverage per tank. If <br /> the party designated b ow is different than the permit applicant, e.g. property owner, the pa must acknowledge this <br /> responsibility for the billi g by signature and date below. <br /> NAME Carl W nderson TITLE Contractor PHONE# (209)467-7573 <br /> ADDRESS /SPO Brox 313255 -Stockton, CA 95213 <br /> SIGNATURE l�-� 1, /.Z� DATE 6/15/09 <br /> EH230038(revised 02/20/09) <br /> 1 <br />