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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY M <br /> � 11 <br /> 600 East Main Street, Stockton, California 95202 O p <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 TY E BELOW: <br /> ElTANK RETROFIT ❑ PIPING REPAIR/RETROFIT [I UDC UDC REPAICOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone# <br /> � Facility Name US Gasoline Phone# 209 465-8979 <br /> IAddress 7 E MLK (Charter Way) Stockton 95206 <br /> L <br /> TCross Street <br /> Y Owner/Operator Phone# 209 465-8979 <br /> o Contractor Name Service Station Testing-SST INC Phone# (209)465-5577 <br /> N Contractor Address PO Box 31465-Stockton, CA 95213 CA Lic# 962520 Class A/B/C-10,20,38 <br /> T <br /> R Insurer EXEMPT Work Comp# N/A <br /> A <br /> ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 08/10/2014 <br /> 0 ICC Installer's Name N/A Expiration Date N/A <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak demdor,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> Ly^►(�1SeeeeA/ttachment With Conditions) <br /> N Plan Reviewers Name —1 !� <br /> A • I ' `l r I 7 Date �1 'a� �•(J ` <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 CALIFORNIA." <br /> Applicant's Signature <br /> Authorized Agent Date 7/18/14 <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 BQox 31325-Stockton, CA 95213 <br /> SIGNATURE Cl_ L_ DATE 7/18/14 <br /> EH230038(revised 02/20/09) <br /> 1 <br />