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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAUIN 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 EPA Site# Project Contact&Telephone# <br /> � <br /> Facility Name Pacific Pride Card Lock Phone# <br /> I Address 351 N Beckman Rd Lodi 95240 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Van de Pol Enterprises Phone# <br /> o Contractor Name APEC Phone# (209) 943-3000 <br /> N Contractor Address PO Box 55105-Stockton, CA 95205 CA Lic# 341375 Class q/g/C-10 <br /> T <br /> A Insurer State Fund Work Comp# 238-0005332 <br /> c ICC Technician's Name Carl W Henderson (5252923) Expiration Date 07/2g/2012 <br /> T <br /> DICC Installer's Name N/A Expiration Date <br /> R <br /> Tank system work areaDate UST <br /> Tank Size Chemicals Stored Currently <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved proved with conditions ❑ Disapproved <br /> L (See ttachment With Conditions) <br /> A P <br /> N 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." 1� <br /> e��b.� w - /� Title Authorized Agent Date6/24/11 <br /> Applicant's Signatur <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 Technician PHONE# (209)467-7573 <br /> ADDRESS PO Box 31325-Stockton, CA 95213 <br /> „_./ t `� DATE6/24/11 <br /> SIGNATURE <br /> EH230038(revised 02/20/09) <br /> 1 <br />