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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 REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name Shell Phone# 209 834-1220 <br /> 1 Address 1206 E March Lane Stockton 95210 <br /> L <br /> I Cross Street <br /> TPhone# 209 834-1220 <br /> Y Owner/Operator DP & DK Investments, Inc <br /> C 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-10,20,36 <br /> T <br /> R Insurer EXEMPT Work Comp# N/A <br /> A <br /> Q ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 08/10/2014 <br /> T <br /> ° ICC Installer's Name N/A Expiration Date N/A <br /> R <br /> Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See A chment With Conditions) <br /> A <br /> N Plan Reviewers Name C 1�' �� Ct�1 I � 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: "1 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 RING OR <br /> WORKER'S <br /> IN THE PERFORMANCE THE SWORK FOR WHICH S H THPERMIIOF CALIFORNIA." T IS ISSUED,D,I SHALL EMPLOY PIFOLLOWING:NG SIGNATURE CERTIFIES THE <br /> E SONS SUBJJEC TO WORKER'S <br /> THAT COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Title Authorized Agent Date 2/8/14 <br /> Applicant's Signature <br /> -- - - BILLINGANFORMATIOW- <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 31325- Stockton, CA 95213 <br /> SIGNATURE <br /> f7� DATE 2/8/14 <br /> EH230038(revised 02/20/09) <br /> 1 <br />