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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 /> ❑TANK RETROFIT OPINING REPAIR/RETROFIT XUDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> O Facility Name E,M%I F6o 6 Nfk2T Phone#(Zyq) 93$ — 74077 <br /> L Address I`IDS CALk$eA NSR S-r — FSLR "N C4 9.S3Z_6 <br /> TCross Street <br /> Y Owner/Operator G1�0 CO Phone# <br /> C Contractor Name HMC-Henderson Maint Co Phone# (209)467-7573 <br /> T Contractor Address PO Box 31325 - Stockton, CA 95213 CA Lic# 856771 Class 021 - D40 <br /> A Insurer REDWOOD FIRE AND CASUALTY INSURANCE CO Work Comp# 4404008536-081 <br /> Q ICC Technician's Certification Number (—uT' Expiration Date 68 <br /> T S csOo4 p' 2-lS— <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 ❑Approved L4proved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name&4_ Bf N Date ?/36/Or <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 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 Signeturec-__ i, Title 0`"' 2 C"�-R � Date ^ /Q'-408 <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 W Henderson TITLE Owner PHONE# (209)467-7573 <br /> ADDRESS PO Box 31325 -./Stockton, CA 95213 <br /> SIGNATURE t--• <br /> EH230038(revised 12/31/07) <br /> 1 <br />