Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMEG&-IVES-=' <br /> SAN JOAQUIN COUNTY SEP 2 9 2015 <br /> 600 East Main Street, Stockton, California 95202 IRONMENTAI <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 r,,�NVIR ner,nr),eer_e1T <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 National Petroleum Phone# 209 463-7716 <br /> 1 Address 3440 E Main St Stockton 95205 <br /> L <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Phone# 209 463-7716 <br /> o Contractor Name Service Station Testing- SST INC Phone# (209) 465-5577 <br /> N <br /> T Contractor Address PO Box 31465 - Stockton, CA 95213 CA Lic# 962520 Class A/B/C-10,20,36 <br /> R Insurer EXEMPT Work Comp# <br /> A N/A <br /> T ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 08/09/2016 <br /> o <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 /> p.e.87 piping sump,91 leak detector.UDC 112,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions ❑ Disapproved <br /> L (Seelttachment With Conditions) <br /> A ( C/ oz/1. <br /> N Plan Reviewers Name 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 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 Signature _ ,gy�--- Title President Date 9/29/15 <br /> [ <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- SST PHONE#(209)465-5577 <br /> ADDRESS PO Box 31465 - Stockton, CA 95213 <br /> SIGNATURE `�— DATE 9/29/15 <br /> EH230038(revised 02/20/09) <br /> 1 <br />