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12/30/2009 07:10 209-465-4482 HMC PAGE 01/02 <br /> ENVIRONMENTAL HEALTH DEPARTMEWT, © 20 NNW <br /> SAN JOAQUIN COUNT' 09 <br /> 600 East Main Street,Stockton California 95202 ;< <br /> !!=�•L I I CCc�?Tr iCfVT <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 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 /> C Contractor Name HMC-Henderson Maintenance Company Phone# (209)467-7573 <br /> 0 <br /> N <br /> 7 Contractor Address PO Box 31325-Stockton,CA 95213 CA Lic# 856771 Ciass D21 /D40 <br /> R <br /> A Insurer State Fund Work Comp# 1908193 <br /> T ICC Technician's Name6j AV 1�j_W i 0 CA A4s" 801(o Z-58—vT Expiration Date 8'q—Zo1 U <br /> 0 ICC Installer's Name NIA P <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87piong sump.91 leak dete=r,UDC 112,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 !V (C) c 1 Date 7 ! 1 `I ;�' 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: "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 /> Applicant's Signature Contractor pie I Z-Lg—0 <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 /> (SAME Carl W Henderson TITLE Contractor PHONE* (209)467-7573 <br /> ADDRESS PO Box 31325-Stockton,CA 95213 <br /> SIGNATUREt�� 1. - - �"� DATE <br /> EH230038(revised 02120109) <br /> 1 <br />