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V <br />ENVIRONMENTAL HEALTH DEPARTMEq "El <br />SAN JOAQUIN COUNTY DEC 12 201 <br />600 East Main Street, Stockton, California 95202 ENVIRONMCNTAL 8EA[ <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 DEPART �NT <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMI <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIRtRETROFIT 0 UDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br />F <br />EPA Site <br />Project Contact & Telephone # <br />A <br />C <br />Facility NamePhone# <br />Mar+ .1 <br />05-1- 46 32 <br />L <br />Address L I Docadri 154oa k4oll (A <br />1 <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone 516 -!7-tl5'06 <br />C <br />0 <br />Contractor Name Service Station Testing - SST INC <br />Phone # (209) 465-5577 <br />N <br />Contractor Address PO Box 31465 - Stockton, CA 95213 <br />CA Lic # 962520 Class A /B / C-10,20,36 <br />T <br />R <br />A <br />Insurer EXEMPT <br />Work Comp # N/A <br />C <br />T <br />[CC Technician's Name Carl Wayne Henderson (5252923) <br />Expiration Date 08/09/2016 <br />0 <br />R <br />ICC Installers Name N/A <br />Expiration Date <br />N/A <br />Tank system work area <br />Tank Size Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump. 91 leak detector, UDC 112, etc.) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved XApproved With conditions � Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <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 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_ rTitle Authorized Agent Date I -Z -/Z -/C <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 fbr�4he billing by signature and date below. 670)5--5-7-q"m6 <br />NAME —TITLE President —PHONE # t2ftr467-*n <br />EH230038 (revised 02/20/09) <br />111wovik4it, 11 011 111111 , i <br />HEALTH <br />111 <br />TE I Z -/17 4 <br />