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a <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />A SAN JOAQUIN COUNTY <br />' 600 East Main Street, -Stockton, California 95202 <br />TelephQpea (209)'468-3420 ` Fax: (209) 468-3433 <br />APPLICATIAN,EOR UNDERGRQUND STORAGE TANK RETROFIT OR PIPING REPAlR PERMIT <br />THIS PERMIT"txPIRES 180 DAYS FROM TH4 APPROVAL•DATE. INbICATE PERMIT TYPE BELOW: <br />❑ TANK, RETROFIT ❑ PIPING REPAIR/RETROFIT. ❑ UDC REPAIR/RETROFIT ❑ COLD START/E1:R UPGRADE <br />F <br />EPA Site # <br />Proje6t Contact & Telephone # ' <br />Facility Name Arco - Mossdale <br />Phone # 209 <br />L <br />Address 444''Mossdale Rd, Lathrop 95330 ; <br />T <br />Cm'at <br />Y <br />Owner/Operator Auburn 770'Inc • <br />Phone # 209 <br />o <br />Contractor Name Service Station Tesbng -;SST INC <br />'Phone # (209) 465-5577 °• <br />T' <br />Contractor Address PO Box 31465 -Stockton, CA 95213 <br />CA Lic # 962520 Class A /B / C-1 0,20,36 <br />A <br />Insurer EXEMPT <br />Work Comp # N/A <br />T <br />ICC jechnician's Name 'Cad Wayne Henderson (5252923) <br />Expiration Date 08/10/2014 <br />R <br />ICC^ Installer's Name N/A <br />Expiration Date N/A <br />Tank system worl�pteeTank <br />Size, ' <br />Chemicals Stored Currently <br />Date UST <br />6 0.e. 87 piping sump, 91 Mak detector, UDC 1Q, etc.) <br />Installed <br />T 0 <br />A <br />' <br />,N <br />K <br />P <br />L❑, ,lpproved �pproved With conditions ❑ Disapproved <br />'L <br />(See Attachment .With Conditions) <br />A <br />N <br />Plan Reviewers Name Y.1Q%%gn 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 />Applicent'sSignatur.rree Authorized Agent D t,11%27/13 <br />BILLING. INFORMATION: <br />tndicatg the responsible party to be trilled for additional EMD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is diffeitent than the permit applicont, e.g: property owner,- the party must acknowledge this <br />responsibility for the billing by signature and date below. , <br />a <br />' NAME Carl Wayne Henderson. • �� TITLE .President PHONE # (209) 467-7573 <br />a <br />ADDRESS PO Boz 31325 - Stockton, CA.. 95213 <br />SIGNATURE (�� ti- = /�� DATE 11/27/13 <br />u <br />" EH230038 (rented 02/20/09) y <br />