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I�r.s�Z <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 ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> c Facility Name System Transport, INC Phone# 209 983-8062 <br /> y <br /> I Address 707 E Roth Rd French Camp 95213 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Sam Abundis Phone# 209 983-8062 <br /> o Contractor Name APEC Phone# (209)943-3000 <br /> N Co tractor Address PO Box 55105-Stockton, CA 95205 CA Lic# 341375 Class A/BIC-10 <br /> T <br /> RIn ter State Fund Work Comp# 238-0005332 <br /> A <br /> T IC Technician's Name Carl W Henderson (5252923) Expiration Date 07/28/2012 <br /> U I# Installer's Name N/A Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> I.e.87 piping wmp,91 leak detector,UDC In,eta) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Attachment With Conditions) <br /> A _ <br /> N PI n Reviewers Name '-tom l�� A/a Date Os - <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 WORK R'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN T11EPEIFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OFCALIF RNIA." / <br /> Applicant signature '--+ `-- ✓ J Tit. Authorized Agent Date5/25/11 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond pennit 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 Technician PHONE# (209)467-7573 <br /> ADDRE /PO Box 31325 -Stockton, CA 95213 <br /> SIGNAT RE r`"P DATE5/25/11 <br /> EH2300 (revised 02/20/09) <br /> 1 <br />