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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 STARTIEVR UPGRADE <br /> FA <br /> EPA Site# Project Contact&Telephone# <br /> Phone#Facility Name Alpha Fast Gas Waterloo RdStockton95205Address 2358 E <br /> 11 <br /> Cross Street <br /> T Phone# <br /> Y Owner/Operator Jimmy <br /> G Contractor Name Service Station Testing-SST INC Phone# 465-5577 465-5577 <br /> ° CA Lic# 962520 Class AIB 1 C-10,20,36 <br /> N Contractor Address PO Box 31465-Stockton, CA 95213 <br /> T Work Comp# NIA <br /> A <br /> R Insurer EXEMPT <br /> G ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 08/1012014 <br /> T <br /> ° ICC Installers Name N/A Expiration Date NIA <br /> R Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e.e7 piping sump.91 Leak detemor,UM 1/2,810 <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved LlApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> RING TO WOT INRKER'S COMPENSATION THE PERFORMANCE OFLAWSTHE OF CALIFOR <br /> FOR M." TONS RACTO7R'S S'S HIS ,I <br /> U D,I SHASUBCONTRACTING I <br /> L EMPLOY PERSONS SUBJECT TOWORKER'SFIES OCOM COMPENSATION LAWS <br /> OF CALIFORNIA:' <br /> Authorized Agent Dale 1124113 <br /> Applicant's SignatTitle <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 <br /> ?resident PHONE# (209)467-7573 <br /> ADDRESS PO Box 31325- Stockton, CA 95213 <br /> DATE 1124113 <br /> SIGNATURE <br /> EH230038(revised 02120109) <br /> 1 <br />