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12/30/2009 07: 10 209-465- 'Q98 Q98 HMC PAGE 011'02 <br /> DoSri�3g r - INA <br /> ENVIRONMENTAL HEALTH DEPARTMEWT I� <br /> © zoos <br /> SAN JOAQUIN '�COUNTY s� jOAoUriv carr rV <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 ARCO-Manteca Phone# 209 825-6784 <br /> 1 Address 1100 S Main St Manteca 95337 <br /> L <br /> TCross Street <br /> Y Owner/Operator Jessie Phone# 209 825-6784 <br /> o Contractor Name HMC-Henderson Maintenance Company Phone# (209)467-7573 <br /> N <br /> 7 Contractor Address PO Box 31325-Stockton,CA 95213 CA Lic# 856771 Class D21 /D40 <br /> R <br /> A Insurer State Fund Work Comp# 1908193 <br /> T ICC Technician's NameC-1 AV'[,,, �;11��✓Lls 80 f to Z.$$—V i Expiration Date 8'q—Zo1 U <br /> o ICC Installer's Name N/A P <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (t,a.87 piping sump,91 leak deteaar.UDC 12,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 I\j (I> c'I Date r 2/ 0 i <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: 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 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA." tS <br /> Applicant's Signature( ,c.�t - / Tale Contractor Date /Z"Zc7!O <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 W Henderson TITLE Contractor PHONE# (209)467-7573 <br /> ADDRESS //PC�O Box 31325-Stockton,CA 95213 <br /> SIGNATURE ( .t 1.-- - f' '� DATE—1 Z^ 2-g. 4 <br /> EH230038(revised 02120109) <br /> 1 <br />