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HEALTHENVIRONMENTAL <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 <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name Waterloo Food & Fuel <br />Phone # 209 466-5816 <br />I <br />Address 3032 E Waterloo Rd <br />Stockton 95205 <br />L <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator <br />Phone # 209 466-5816 <br />Contractor Name HMC - Henderson Maintenance Company <br />Phone # (209) 467-7573 <br />C <br />NCA <br />Contractor Address PO Box 31325 -Stockton, CA 95213 <br />Lic # <br />856771 Class D21 / D40 <br />T <br />R <br />Insurer State Fund <br />Work Comp # 1908193 <br />A <br />ICC Technician's Name <br />Expiration Date <br />T <br />oICC <br />R <br />Installer's Name N/A <br />Expiration Date <br />Tanks stem work area <br />y <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />❑ Approved Approved with conditions <br />(See Attach ent With Conditions) <br />Plan Reviewers Name Date <br />❑ Disapproved <br />& i I <br />P <br />L <br />A <br />N <br />v t <br />APPLICANT MUST PERFORM ALL WORK IN ACCOR WITH SAN JOAQUIN COON DINANCES, STATE LAWS, AND RULES AND REGULATIONS F A <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEP R ENT. 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 <br />WORKER'S <br />IN THE PERFORMANCEOF THEWORKFOR WHICH THIS CONTRACTOR'S <br />IS ISSUED, I SHALL EMPLOY PICERTIFIES <br />OF CALIFORNIA." E SONS SUBJECTNG SIGNATURE TOWORKER'SFOLLOWING: <br />THAT COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's SignatureC� L.—' Title Contractor Date 2 �� <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 />MAKAG Carl W Henderson TITLE Contractor PHONE# (209) 467-7573 <br />ADDRESS PO Box 31325 - Stockton, CA 95213 <br />SIGNATURE `"'r DATE 7/2/10 <br />EH230038 (revised 02/20/09) <br />1 <br />