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SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />•- • t-1 '91, 4 - -• i LT 1:91 -. -0 . <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RFTROFIT PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name Waterloo Food and Fuel <br />Phone # 209-466-5816 <br />I <br />L <br />Address 3032 E. Waterloo Rd. Stockton, Ca 95205 <br />TCross <br />Street <br />Y <br />Owner/Operator Paul <br />Phone # 209-466-5816 <br />C <br />0 <br />Contractor Name HMC <br />Phone # 209-467-7573 <br />N <br />T <br />Contractor Address P,O Box 31325 Stockton , Ca 95213 <br />CA Lic # 856771 Class C61/D21 C61 /D <br />A <br />Insurer Redwood <br />Work Comp # 4404008536-081 <br />C <br />T <br />ICC Technician's Certification Number <br />Expiration Date <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Date UST Installed <br />Currently/Previously <br />T <br />A <br />N/A <br />N <br />K <br />P <br />❑Approved Approved with conditions ❑Disapproved <br />P�ttachnnent <br />L <br />ee With Conditions) <br />A <br />4E <br />N <br />Plan Reviewers NameDate <br />2C <br />I <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 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 TO <br />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 />Applicants 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 Wayne Henderson TITLE Owner <br />ADDRESS P. O Box 31325 Stockton, Ca 95213 <br />SIGNATURE(/t.. <br />EH230038 (revised 12/31/07) <br />1 <br />PHONE# 209-461-7573 <br />