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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 Freeway Shell Phone# <br /> I Address 7700 E Moreland Ct Stockton 95212 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> C Contractor Name Service Station Testing SST INC Phone# (209 465-5577 <br /> Q g- ) <br /> N <br /> T Contractor Address PO Box 31465 -Stockton, CA 95213 CA Lic# 962520 Class A/B!C-10,20,36 <br /> R <br /> A Insurer EXEMPT Work Comp# N/A <br /> T ICC Technician's Name Charles A. Ferrucci (5323096) Expiration Date 01/11/2013 <br /> Q ICC Installer's Name N/A p N/A <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,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 <br /> N Plan Reviewers Name Date / <br /> _77- <br /> APPLICANT MUST PERFORM ALL WO, IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENT 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 /> en <br /> Applicant's Signature .... . / Title Authorized Agent Date <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 Box 31325 - Stockton, CA 95213 <br /> ("� [[�� <br /> SIGNATURE �"� "" DATE _Co— <br /> EH230038(revised 02/20/09) <br /> 1 <br />