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SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />-- • Ll I&I M I I L,r - • •-. - -• • - -Eel -4:7-111 - :I r <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 />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name Pacific Pride <br />Phone # <br />I <br />L <br />Address 351 N Beckman Rd Lodi 95240 <br />TCross <br />Street <br />Y <br />Owner/Operator Van de Pol Enterprises <br />Phone # <br />o <br />Contractor Name Service Station Testing - SST INC <br />Phone # (209) 465-5577 <br />NContractor <br />T <br />Address PO Box 31465 - Stockton, CA 95213 <br />CA Lic # 962520 Class A /B / C-10,20,36 <br />A <br />Insurer EXEMPT <br />Work Comp # N/A <br />T <br />IGC Technician's Name Carl Wayne Henderson (5252923) <br />Expiration Date 08/10/2014 <br />o <br />R <br />ICC Installer's Name N/A <br />Expiration Date N/A <br />Tank system work area <br />1/2, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC etc.) <br />T <br />A <br />N <br />K <br />❑ Approved ❑ Disapproved <br />P <br />Approved with conditions <br />L <br />A <br />e ttachment With Conditions) In <br />i <br />N <br />✓ i� <br />Plan Reviewers Name 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 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 V~ Title Authorized Agent pie 7/1 /13 <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 />ADDRESS PO Box 31325 - Stockton, CA 95213 <br />SIGNATURE L'' ! DATE 7/1/13 <br />EH230038 (revised 02/20/09) <br />0 <br />