Laserfiche WebLink
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-Tracy Phone# <br /> L Address 1535 Pescadero Ave Tracy 95304 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Yellow Freight Phone# <br /> o 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 q/B/C-10,20,36 <br /> A Insurer EXEMPT Work Comp# N/A <br /> C ICC Technician's Name Carl Wayne Henderson ) 08/10/2014 <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 /> (i e.87 piping sump,911eak detector,UDC 12,etc) Installed <br /> T <br /> A <br /> IN <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A ] <br /> N Plan Reviewers Name nz,.� - Date l __2_ O <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: "1 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 tom-..! �— /"'-- T1de Authorized Agent Date 12/11/13 <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 l�t-� �- i+" —'— T DATE 12/11/13 <br /> EH230038(revised 0220/09) <br />