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ORIGINAL <br />ENVIRONMENTAL HEALTH DEPART <br />SAN JOAQUIN COUNTY <br />600 <br />600 East Main Street, Stockton, California 95202 JAN 2 7 2015 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPIFWL. <br />FP.q RTn, <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: �FN7 <br />❑ TANK RETROFIT ❑ 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 Parkwoods Shell <br />Phone # <br />I <br />L <br />Address 1612 W Hammer Ln Stockton 95209 <br />TCross <br />Street <br />Y <br />Owner/Operator Paul Singh <br />Phone # <br />C <br />Contractor Name Service Station Testing - SST INC <br />Phone # (209) 465-5577 <br />N <br />T <br />Contractor Address PO Box 31465 - Stockton, CA 95213 <br />CA Lic # 962520 Class A /B / C-10,20,36 <br />A <br />Insurer EXEMPT <br />Work Comp # N/A <br />T <br />ICC Technician's Name Carl Wayne Henderson (5252923) <br />Expiration Date 08/09/2016 <br />o <br />R <br />ICC Installer's Name N/A <br />Expiration Date <br />p N/A <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />❑ Approved ❑ Disapproved <br />P <br />Approved with conditions <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />_4Q <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 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 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." %� Q <br />Authorized Agent 1/26/15 <br />Applicant's 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 Carl Wayne Henderson TITLE President PHONE # (209) 467-7573 <br />ADDRESS PPO Box 31325 - Stockton, CA 95213 <br />SIGNATURE ! t� /� DATE 1/26/15 <br />EH230038 (revised 02/20/09) <br />1 <br />