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A <br />SAN JOAQUIN <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 <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />O <br />R <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />EPA Site # <br />Facility Name Shell Food Mart <br />Address 2320 N <br />Cross Street <br />Owner/Operator Bob Lutz <br />Project Contact & Telephone # <br />EI Dorado St <br />Contractor Name Service Station Testing - SST INC <br />Contractor Address PO Box 31465 - Stockton, CA 95213 <br />Insurer EXEMPT <br />ICC Technician's Name Carl Wayne Henderson (52529 <br />ICC Installer's Name N/A <br />Tank system work areaI Tank Size <br />(Le. 87 piping sump, 91 leak detector, UDC 1/2, etc) <br />Phone # 209 943-1311 <br />Stokton 95209 <br />Phone # 209 943-1311 <br />Phone # (209) 465-5577 <br />CA Lic # 962520 Class A /B / C-10,20,36 <br />Work Comp # N/A <br />Expiration Date 08/10/2014 <br />Expiration Date N/A <br />Date UST <br />Chemicals Stored Currently Installed <br />❑ Approved Approved with conditions El Disapproved <br />See A achment With Conditions) <br />Dates <br />Plan Reviewers Name <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 F R WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />re <br />V'- - Title Authorized Agent Date 6/9/14 <br />Applicant's Signatu <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 />PO Box 31325 - <br />EH230038 (revised 02/20/09) <br />CA 95213 <br />0 <br />6/9/14 <br />