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ORIGINAL <br /> 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 /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> ephone# <br /> F EPA Site# Project Contact&Tel <br /> Phone# 209 834-1220 <br /> � Facility Name Karam Singh <br /> � <br /> Address 3400 N Mac AntherTracy 95376 <br /> T Cross Street <br /> Phone# 209 834-1220 <br /> Y Owner/Operator Tracy Petro, INC <br /> D Contractor Name Service Station Testing-SST INC <br /> Phone# (2pg)465-5577 <br /> oCA Lic# 962520 Class A/B/C-10,20,36 <br /> " Contractor Address PO Box 31465-Stockton, CA 95213 <br /> T Work Comp# NIA <br /> R Insurer EXEMPT <br /> AExpiration Date 08/09/2016 <br /> C ICC Technician's Name Carl Wayne Henderson (5252923) <br /> T <br /> oICC Installer's Name N/A Expiration Date N/A <br /> R Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> 1,e.87 piping sump.91 leak detector.UM 12,etc.) <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approv Approved nditions ❑ Disapproved <br /> L (S Attachment Wit onditions) <br /> A I <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CGLa 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 /> Applignfs Signature L-- / Title Authorized Agent Date 11/6/14 <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 /> SIGNATURE y' DATE 11/6/14 <br /> EH230038(revised 02/20/09) <br /> 1 <br />