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0 1 . 0 <br /> 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 /> 54 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 Kwik Sery-Tracy Phone# 209 832-1810 <br /> 1 Address 950 W 11th Tracy 95376 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# 209 832-1810 <br /> C Contractor Name HMC-Henderson Maintenance Company Phone# (209)467-7573 <br /> O <br /> N Contractor Address PO Box 31325-Stockton, CA 95213 CA Lic# 856771 Class D21 /D40 <br /> T <br /> A Insurer State Fund Work Comp# 1908193 <br /> T ICC Technician's Name Expiration Date <br /> Gavin Williams p <br /> o <br /> R ICC Installer's Name N/A 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 /> Le Attachment With Conditions) <br /> A - <br /> N <br /> 9 0Plan Reviewers rs Na Date <br /> APPLICANT MUST PERFORM ALL WORK iN-AC41DANCE 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 Title Contractor pie 8/5/10 <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 PO Box 31325-Stockton, CA 95213 <br /> SIGNATURE�A� �'�—• DATE 8/5/10 <br /> EH230038(revised 02/20/09) <br /> 1 <br />