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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 REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone# <br /> � <br /> Facility Name Yellow Freight Phone# 209 <br /> L Address 1535 Pescadero Ave Tracy 95304 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Yellow Freight Phone# 209 <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-10,20,36 <br /> T <br /> A Insurer EXEMPT Work Comp# N/A <br /> T ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 07/28/2012 <br /> a 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 pilkng sump,91 leak tl aor.UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A 2 <br /> C0-APN Plan Reviewers Name Date 6pz 3 10- <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 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 /> Appliwnfs Signature ±! L•-- �" Title Authorized Agent oat.2/15/12 <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 31.3/2`55-Sttoc�kton, CA 95213 <br /> SIGNATURE DATE 2/15/12 <br /> EH230038(revised 0220/08) <br /> 1 <br />