Laserfiche WebLink
i <br /> 0 • <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 I9 PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone# <br /> � <br /> Facility Name Texaco-Emil's Liquor Phone# 209 838-7674 <br /> IAddress 1405 California St Escalon 95320 <br /> L <br /> I Cross Street <br /> T Phone 209 838-7674 <br /> Y Owner/Operator Chacko Thomas <br /> c Contractor Name Service Station Testing-SST INC Phone# (209)465-5577 <br /> no CA Lic# 962520 Class A B/C-10,20,36 <br /> Contractor Address PO Box 31465-Stockton, CA 95213 <br /> R Work Comp# N/A <br /> A Insurer EXEMPT <br /> C ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 07/28/2012 <br /> T <br /> D ICC Installer's Name N/A Expiration Date N/A <br /> R <br /> Date UST <br /> Tank system work area <br /> Tank Size Chemicals Stored Currently Installed <br /> (i.e.87 piping wmp,91 leak Eelerlpn UDC 12,etc.) <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved With conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A SItC�l2 <br /> N Date <br /> Plan Reviewers Name {� rv• p�w� <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: 9 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 /> Applimrd's Signature <br /> l.a�' (^"' �i ritia Authorized Agent Dae 5/3/12 <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 /SPO Box 31325-Stockton, CA 95213 <br /> SIGNATURE f_ +j ,_J.-e— DATE 5/3/12 <br /> EH230038(revised 02/20/09) <br /> 1 <br />