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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 /> F.TANK RETROFIT PIPING REPAIR/RETROFIT UUDC REPAIR/RETROFIT 'COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> Facility Name 76- Lodi "COUNTRYSIDE" Phone# [209]948-1684 <br /> 1Address <br /> L 14971 N Hwy 88 Lodi, CA 95240 <br /> I Cross Street Kettlernan <br /> T <br /> Y Owner/Operator Vic Phone# [209] 968-8553 <br /> o Contractor Name HMC-Henderson Maint Co Phone# (209)467-7573 <br /> N Contractor Address PO Box 31325 - Stockton, CA 95213 CA Lie# 856771 Class D21 -D40 <br /> T <br /> A Insurer REDWOOD FIRE AND CASUALTY INSURANCE CO Work Comp# 4404008536-081 <br /> C <br /> T ICC Technician's Certification Number Expiration Date <br /> O <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P YXpproved with conditions EDisapproved <br /> A (See Attachment With Conditions) <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 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 ^���-l V Date G <br /> D .G <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended ueyond 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 W Henderson TITLE Owner PHONE# (209)467-7573 <br /> ADDRESS PO Box 31325 - Stockton, CA 95213 <br /> SIGNATURE <br /> EH230038(revised 12/31!07) <br /> 1 <br />