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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 />I]TANK RETROFIT )41PING REPAIRIRETROFIT I_IUDC REPAIR/RETROFIT F (COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name Arco <br />Phone # (209) 466-9516 <br />1 <br />L <br />Address y <br />130 S Wilson Wa <br />I <br />Cross Street HWY 4 <br />T <br />Y <br />Owner/Operator Lawrence <br />Phone # <br />o <br />Contractor Name HMC - Henderson Maint Co <br />Phone # (209) 467-7573 <br />T <br />Contractor Address PO Box 31325 - Stockton, CA 95213 <br />CA I_ic # 856771 Class D21 - D40 <br />A <br />Insurer REDWOOD FIRE AND CASUALTY INSURANCE CO <br />Work Comp # 4404008536-081 <br />T <br />ICC Technician's Certification Number 5252923 <br />Expiration Date 8/7/10 <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />Approved -??Approved with conditions ❑Disapproved <br />L <br />(See Attachpent lth Conditions) <br />A <br />N <br />C' 'gam 2 - 11-2o& <br />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 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 TO <br />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 />Applicants SignaturZ= �--- Title Contractor Dte 2/7/09 <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 />Carl W Henderson <br />PO Box 31325 - Stockton, CA 95213 <br />SIGNATURE CA-1� i- <br />EH230038 (revised 12/31/07) <br />TITLE Owner PHONE # (209) 467-7573 <br />1 <br />