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DECENVIRONMENTAL HEALTH DEPARTMER CEIVI <br />SAN JOAQUIN COUNTY <br />600 East Main Street,t t California 95202 <br />ENVIRONMENTALTelephone: (209) 468-3420 Fax: (209) 468-34334PPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERM <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name <br />Phone # _ j- <br />1 <br />L <br />Address (� ick a:rt C'Q <br />T <br />Cross Street 4 <br />Y <br />Owner/Operator Av l7 <br />Phone # -5,10 ':j27 — Q <br />c <br />0 <br />Contractor Name Service Station Testing - SST INC <br />Phone # (209) 465-5577 <br />N <br />T <br />Contractor Address PO Box 31465 - Stockton, CA 95213 <br />1 CA Lic # 962520 Class A /B/C-10,20,36 <br />RInsurer <br />A <br />EXEMPT <br />Work Comp # NIA <br />T <br />ICC Technician's Name Carl Wayne Henderson (5252923) <br />Expiration Date 08I09/2016 <br />o <br />R <br />ICC 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 />(.e. 87 piping sump, 91 leak detector, UDC 1/2, etc) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See A achment With Conditions) <br />A <br />N <br />rr <br />�% <br />Plan Reviewers NamefflDate c L <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 AGENT'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." <br />Applicant's Signature Title Authorized Agent Date (2 fZ -If <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. (Vp)5377_rgs-p6 <br />V'an`�� Sin h <br />NAME TITLE President PHONE # _f2ewf7-7R& <br />ADDRESS P <br />SIGNA' <br />EH230038 (revised 02/20/09) <br />1 <br />2"f;? %1+ <br />