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ENVIRONMENTAL HEALTH DEPARTMW'bEIVED <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton,California 95202 OCT 18 2013 <br /> Telephone: (209)468-3420 Fax: (209)465-3433 <br /> ENVIRONM AL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING NMM* T <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETRORT ❑ COLD START/EVR UPGRADE <br /> F EPA Ste# Project Contact&Telephone# <br /> C Facility Name Kwik Sery Phone# 209 823-8800 <br /> I <br /> L Address 824 E Yosemite Manteca 95336 <br /> TCross Street <br /> Y Owner/Operator Mike Hamed Phone# 209 823-8800 <br /> D Contractor Name Service Station Testing -SST INC Phone# (209)465-5577 <br /> 0 <br /> TN Contractor Address PO Box 31465-Stockton, CA 95213 CA Lic# 962520 Class AIB/C-10,20,36 <br /> R Insurer EXEMPT Work Comp# N/A <br /> A <br /> ICC Technidan's Name Carl Wayne Henderson (5252923) Expiration Date 08/10/2014 <br /> DICC Installer's Name N/A Expiration Date N/A <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak deter ,UDC 1Q.etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved 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 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 /> APplirant's Slgnatu I" ' �"` rme Authorized A ent Date 10/18/13 <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 g (209)467-7573 _ <br /> ADDRESS PO Box 31325-Stockton, CA 95213 <br /> Cl^ ,, <br /> SIGNATURE w-- /� DATE 10/18/13 <br /> EH230038(revised 02120109) <br /> 1 <br />