Laserfiche WebLink
0 0 D, ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPART <br /> SAN JOAQUIN COUNTY WEEIVED <br /> 600 East Main Street, Stockton, California 95202 V„AY 15 2D15 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> EyyI�� NMENTALHEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPINGNV4 Iii; T <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name Texaco- Escalon Phone# 209 8387674 <br /> I <br /> L Address 1405 California St Escalon 95320 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Chacko Phone# 209 8387674 <br /> C Contractor Name Service Station Testing-SST INC Phone# (209)465-5577 <br /> T Contractor Address PO Box 31465-Stockton, CA 95213 CA Lic# 962520 Class A/B/C-10,20,36 <br /> R Insurer <br /> A EXEMPT Work Comp# N/A <br /> D ICC Technician's Name Carl Wayne Henderson ) 08/09/2016 <br /> T y (5252923 Expiration Date <br /> R ICC Installer's Name N/A Expiration Date N/A <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le,87 piping sump.et leak detector,UDC 12.eta) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name &yw I I Iud n Date 5—t —CqQLu <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 AGENT'S 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 CALIFORNIA." <br /> Applicant's Signature Tine Authorized Agent Dle5/14/15 <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 /> ADDRESS /PO Brox 31325-Stockton, CA 95213 <br /> SIGNATURE DATE5/14/15 <br /> EH230038(revised 02/20/09) <br /> 1 <br />