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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 EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name Yellow Freight Phone# <br /> I Address 1535 Pescadero Ave Tracy 95304 <br /> I Cross Street <br /> T <br /> y Owner/Operator Phone# <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 1 G10,20,36 <br /> T <br /> A Insurer EXEMPT Work Comp# NIA <br /> C ICC Technician's Name y ( ) <br /> T Carl Wayne Henderson 5252923 Expiration Date_ 08/10/2014 <br /> oICC Installers Name <br /> R ' NIA Expiration Date NIA <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> p e 87 p+ping sump.91 leak delector,UDC 112,elc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> ateAPN Plan Reviewers Name Date— <br /> APPLICANT <br /> PLICANT 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 Signaturel —/ '— / Title Authorized Agent Date$128112 <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 /> Al PO Box 31325 - Stockton, CA 95213 <br /> SIGNATURE - DATE 8128/12 <br /> LH230038(revised 02120100) <br /> 1 <br />