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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 REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name ABC Food Mart-Valero Mr Cafe Phone# <br /> I Address 13 N Stockton 95202 <br /> L EI Dorado St <br /> I Cross Street <br /> T <br /> Y Owner/Operator Vic Judqe Phone# X <br /> o Contractor Name APEC Phone# (209) 943-3000 <br /> N <br /> T Contractor Address PO Box 55105-Stockton, CA 95205 CA Lic# 341375 Class A/B/C-10 <br /> A Insurer State Fund Work Comp# 238-0005332 <br /> T ICC Technician's Name Carl W Henderson (5252923) Expiration Date 07/28/2012 <br /> R ICC Installer's Name N/A Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P J Approved pproved with conditions �_� Disapproved <br /> L (See Attachment ith Conditions) <br /> A Z p (( <br /> N Plan Reviewers Name 14 Date-4 4Z <br /> Z / <br /> d✓ <br /> r-.i� <br /> APPLICANT MUST PERFORM ALL WORK IN ACC RD NCE WITH SAN JOAQUIN RDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 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." oc <br /> Applicant's Signature �� ��f Title Authorized Agent Date5/25/11 <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 Technician PHONE# (209)467-7573 <br /> ADDRESS PO Box 31325 -/Stockton, CA 95213 <br /> SIGNATURE ~' �' �— DATE 5/25/11 <br /> EH230038(revised 02/20/09) <br /> 1 <br /> X <br />