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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 160 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE HELO`A. <br /> A TANK RETROFIT ❑ PIPING REPAIR,RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone# <br /> Phone# 209 465-8979 <br /> Facility Name US Gasoline <br /> 1 Address 749 E MLK(Formerly Charter Way) Stockton 95206 <br /> L <br /> I Cross Street <br /> T Phone# 209 465-8979 <br /> Y Owner/Operator <br /> C Contractor Name HMC -Henderson Maintenance Company Phone# (209) 467-7573 <br /> N Contractor Address PO Box 31325- Stockton, CA 95213 CA Lic# 856771 Class D21 1 D40 <br /> R Insurer State Fund Work Comp# 1908193 <br /> A <br /> c IGC Technician's Name Expiration Date <br /> T <br /> QICC Installer's Name NIA Expiration Date <br /> R ---T <br /> Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (Le.87 piping sump,91 leak detector,uoc 112,etc.) <br /> T <br /> A <br /> N <br /> K <br /> F, L Approved Approved with conditions Disapproved <br /> L (See Attachment VVith Conditions) <br /> A 3 <br /> N Plan Reviewers Name ,46A=====-Date <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." /e `�-�'` `r - N1 -� TRI. Contractor Date r�? 7"'- <br /> Applicant's Signaturr � <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 W Henderson TITLE Contractor PHONE# (209)467-7573 <br /> ADDRESS PO Box 31325 -Stockton, CA 95213 <br /> SIGNATURE r,-- �- <br /> DATE 2 -7 r 0 <br /> EH230038(revised 02/20/09) <br /> 1 <br />