Laserfiche WebLink
i <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 />❑ TANK RETROFIT L9 PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />EPA Site # I Project Contact & Telephone # <br />Facility Name Knife River Corporation <br />Address 655 W Clay St <br />Cross Street <br />Owner/Operator Steve Azevedo <br />Contractor Name Service Station Testing - SST INC <br />Contractor Address PO Box 31465 - Stockton, CA 95213 <br />Insurer EXEMPT <br />ICC Technician's Name Carl Wayne Henderson (5252923 <br />ICC Installer's Name N/A _T <br />Tank system work area Tank Size <br />(i.e. 87 piping sump, 91 leak detector, UDC 12, etc.) <br />CA Lic # <br />Phone # <br />Stockton 95206 <br />Phone # <br />Phone # (209) 465-5577 <br />962520 Class A /B / C-10,20,36 <br />Work Comp # N/A <br />Expiration Date 07/28/2012 <br />Expiration Date N/A <br />Date UST <br />Chemicals Stored Currently Installed <br />❑ Approved Approved with conditions El Disapproved <br />(See Attachment With Conditions) <br />Plan Reviewers Name-y��-l�/J� �/t' Date C) �! Z <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 NG: "I CERTIFY <br />WORKER'S <br />IN THE PERFORMANCE THE LAWS <br />WORK FOR WHICH TOF CALIFORNIA." HIS PERMIT IS SISUED,RING ,II SHALBL EMPLOY PERSONS UBJJEC TO WORKER'S COMPECONTRACTING SIGNATURE CERTIFIES THE NSATION THAT LA S <br />OF CALIFORNIA." <br />Applicant's Signature C11-4 <br />Title Authorized Agent Date 5/10/12 <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 Wayne Henderson TITLE President PHONE # (209) 467-7573 <br />PO Box 31325 - Stockton, CA 95213 <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />1 <br />5/10/12 <br />