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f <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 /> I� TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name ABC Food Mart - Valero Phone# 661 706-3298 <br /> 1 Address 713 N EI Dorado St Stockton 95202 <br /> L <br /> TCross Street <br /> Y Owner/Operator Vic Judge Phone# 661 706-3298 <br /> o Contractor Name Service Station Testing -SST INC Phone# (209)465-5577 <br /> N Contractor Address PO Box 31465 - Stockton, CA 95213 CA Lic# 962520 Class A/B/C-i o,zo,36 <br /> T <br /> A Insurer EXEMPT Work Comp# N/A <br /> T ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 08/10/2014 <br /> Q ICC Installer's Name Expiration Date <br /> R N/A p N/A <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i a 87 piping sump.91 leak detector,UDC 1/2,etc) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved �; Approved with conditions ❑ Disapproved <br /> L (See Attachment Ith Conditions) <br /> A ' <br /> N Plan Reviewers Name Date 13 <br /> APPLICANT MUST PERFORM ALL WORK IN ACC R NCE WITH SAN JOAQUIN CONTY DINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSE ,ENT'S 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." //1 <br /> Applicant's Signature lam✓ t'' Title Authorized Agent Date 5/14/13 <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 Wayne Henderson TITLE President PHONE# (209)467-7573 <br /> ADDRESS PPO Box 31325-Stockton, CA 95213_ _ <br /> SIGNATURE l�-'� t" ' DATE 5/14/13 <br /> EH230038(revised 02/20/09) <br /> 1 <br />