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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 />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name A -One Gas & Food <br />Phone # <br />I <br />L <br />Address 574 W Tracy Blvd Tracy 94566 <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator ADDENDUM SR0068756 <br />Phone # <br />0 <br />C <br />Contractor Name Service Station Testing SST INC <br />g- <br />Phone# (209 465-5577 <br />} <br />N <br />T <br />Contractor Address PO Box 31465 - Stockton, CA 95213 CA I_ic # 962520 Class q /g / C-10,20,36 <br />R <br />A <br />Insurer EXEMPT <br />Work Comp # N/A <br />T <br />ICC Technician's Name Carl Wayne Henderson (5252923) <br />Expiration Date 08/10/2014 <br />° <br />R <br />ICC Installer's Name N/A <br />Expiration Date N/A <br />Tank system work area Tank Size Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector. UDC 12, etc.) <br />T <br />A <br />KArov <br />` <br />DEND VADvSRoo887 <br />5 6P Approved with conditions ❑ Disapproved <br />L <br />(Se Attac nt With Conditions) <br />A <br />N <br />Li <br />Plan Reviewers Name Date77 v <br />APPLICANT MUST PERFORM ALL 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 IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CAUFORNIA:• <br />Applicant's Signature_ Title Authorized Agent Date <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME Carl Wayne Henderson TITLE President PHONE # (209) 467-7573 <br />PO Box 31325 - Stockton, CA 95213 <br />SIGNATU <br />EH230038 (revised 02/20/09) <br />TE 3 -13- -o I y <br />