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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 100 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> IR TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A Facility Name MacArther Chevron Phone_# 209 834-1220 <br /> LAddress 3400 N MacArther Tracy 95376 <br /> L <br /> T Cross Street <br /> Y Owner/Operator Phone# 209 834-1220 <br /> C Contractor Name Service Station Testing-SST INC Phone#(209)465-5577 <br /> N Contractor Address PO Box 31465-Stockton,CA 95213 CA Lie# 962520 Class A B/C-10,20.30 <br /> T <br /> R Insurer EXEMPT Work Comp# NIA <br /> A <br /> T ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 07/28/2012 <br /> 0 ICC Installer's Name N/A Expiration Date N/A <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> r.e.97gpmg> mp.91bas eebeu.UDC Ia.ea) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (SAttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date o 3 06 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$SIGNATURE CERTIFIES THE FOLLOWING' 1 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 COMPENSATION LAWS <br /> OF CALIFORNIA" •L//f <br /> Applilamt's Signature e"" /'�_`� TBk Authorized Agent Data 1 <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 PO Box 31325--(Stockton, CA 95213 <br /> 131 SIGNATURE DATE_.3 / Z_ <br /> EH230038(revised D220I09) <br /> 1 <br />