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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 ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name Yellow Freight-Tracy Phone# <br /> L <br /> Address 1535 Pescadero Ave Tracy 95304 <br /> IT Cross Street <br /> Y Owner/Operator Yellow Freight Phone# <br /> D Contractor Name Service Station Testing-SST INC Phone# (209)465-5577 <br /> 0 <br /> N Contractor Address PO Box 31465-Stockton, CA 95213 CA Lic# 962520 Class A/B/C-10,20,38 <br /> T <br /> R <br /> A Insurer EXEMPT Work Comp# N/A <br /> T ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 08/10/2014 <br /> 0 <br /> R ICC Installer's Name N/A Expiration Date N/A <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (.e.87 piping sump,911eak eeteQar,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ,Approved with conditions iJ Disapproved <br /> L (See Attachment With Conditions) <br /> AL13 <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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 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 `� � '— Tine_ Authorized Agent D.,,12/11/13 <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 3132� /-5Stoc—kton, CA 95213 <br /> SIGNATURE IS—' <br /> L-- h— DATE 12/11/13 <br /> EH230038(revised 0220/09) <br /> 7 <br />