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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3.120 Fax: (209) 468-3.133 <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 /> C Facility Name 76 Express ( Formerly KWIK SERV) Phone# 209 401-5181 <br /> 1 Address 419 S Main Manteca 95366 <br /> L <br /> TCross Street <br /> Y Owner/Operator Bobbie Phone# 209 401-5181 <br /> o Contractor Name HMC-Henderson Maintenance Company Phone# (209)467-7573 <br /> N Contractor Address PO Box 31325-Stockton, CA 95213 CA Lic# Class <br /> T 856771 D21 /D40 <br /> A Insurer Redwood Fire&Casualty Insurance Co Work Comp# 4404008536081 <br /> T ICC Technician's Name Carl Wayne Henderson / 5252923-UT Expiration Date 8/10/10 <br /> o ICC Installer's Name N/A p <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 J <br /> N Plan Reviewers Name Date tI}CI <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 <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 /> L2 . '� Contractor �8�o <br /> Applicant's Signature Title 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 W Henderson TITLE Contractor PHONE# (209)467-7573 <br /> ADDRESS /PCO Brox 31325-Stockton, CA 95213 <br /> SIGNATURE C —A w� DATE d <br /> --- <br /> EH230038(revised 02/20/09) <br /> 1 <br />