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LNVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN :COUNTYk <br />600 Eaiai» Seet, Stockton,�California 95242 <br />yTelepjiione (209),468-3420, 'Fax: (209) 468-3433 <br />,34 .. .. , <br />APPLICATION FOR UNIDiRGIROUND STORAGE,TANK RETROFIT OR PIPING REPAIR PERMIT <br />'THIS PERMIT EXPIRES 160 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑"TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC`REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />C <br />Facility NameTracy Valero <br />Phone #209 833-2236 <br />l <br />L <br />Address 2375 Tracy Blvd " Tracy 95376 <br />Cross Street <br />T`09 <br />Y <br />Owner/Operator , <br />Phone # 2 833-2236 _ <br />C'. <br />O <br />Contractor'Name Service Station Testing - SST INC <br />Phone # (209) 465-5577 <br />NP <br />T <br />Address PO Box 31465 - Stockton, CA 95213: <br />CA Lic # 962520 Class q !B c-10,20,36 <br />R <br />A <br />Insurer EXEMPT <br />Work Comp # N/A <br />T <br />tCC Technician's Name Carl Wayne Henderson (5252923) <br />Expiration Date 08/10/2014. <br />oICC <br />R <br />Installer's Name N/A <br />Expiration Date N/A <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently. <br />Date UST <br />Installed <br />(i.e. 67 piping sump, 91 leak deterdor, UDC 112, etc.) <br />T; <br />A <br />N <br />K <br />... <br />i <br />.. <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />n (Se `Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date_ <br />APPLICANT MUST PERFORM'ALJ_ 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 />APPliwnt's Signature '-- TRle Authorized Agent Date <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 />r 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 />5 NAME Carl Wayne Henderson TITLE' President PHONE # ' , (209) 467-7573 <br />'ADDRESS PO Box 31325 - Stockton, CA 95213 <br />�-� - DATE <br />' SIGNATURE 11/26/13 , <br />EH230038 (revised 02/20/09) <br />