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Ll ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 600 East Main Street, Stockton, California 95202 Telephone: (209) 468-3420 Fax: (209) 468-3433 APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE F EPA Site # Project Contact & Telephone # A C Facility Name 76 Manteca Phone # I L Address 1700 E Manteca 95366 Yosemite Ave TCross Street Y Owner/Operator Phone # o Contractor Name Service Station Testing - SST INC Phone # (209) 465-5577 NContractor T Address PO Box 31465 - Stockton, CA 95213 CA Lie # 962520 Class A /B / C-11 0,20,36 A Insurer EXEMPT Work Comp # N/A T ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 07/28/2012 R ICC Installer's Name N/A Expiration Date N/A Tank system work area Tank Size Chemicals Stored Currently Date UST (i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed T A N K P ❑ Approve Approved with conditions ElDisa proved L A t ' ( e achment With Conditions) N Plan Reviewers Name Date APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." ^ Applicant's Signature l tee. iir `• Title Authorized Agent Date BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAME Carl Wayne Henderson TITLE President PHONE # (209) 467-7573 PO Box 31325 - Stockton, CA 95213 SIGNATURE_(! � DATE 7, EH230038 (revised 02/20/09)