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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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name 7-Eleven/76 Lodi Phone# 209 369-3633 <br /> IAddress 1111 E Kettleman Ln Lodi 95240 <br /> L <br /> TCross Street <br /> Y Owner/Operator Jivtesh Gill Phone# 209 369-3633 <br /> 0c Contractor Name HMC-Henderson Maintenance Company Phone# (209)467-7573 <br /> N Contractor Address PO Box 31325 -Stockton, CA 95213 CA Lic# 856771 Class D21 /D40 <br /> T <br /> R Insurer State Fund Work Comp# 1908193 <br /> A <br /> T ICC Technician's Name Carl Wayne Henderson / 5252923-UT Expiration Date 8/10/10 <br /> DR ICC Installer's Name N/A Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Is.87 piping wmp,gt leak setecmr,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 /> ApplimM's Signature <br /> CL, /y` Tale Contractor D.I. <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 <br /> Carl W Henderson TITLE Contractor PHONE# (209)467-7573 <br /> ADDRESS PO BpGox 31325-Stockton, CA 95213 [� <br /> SIGNATURE(f w DATE //_r 7 _6 I <br /> EH230038(revised 0220109) <br /> 1 <br />