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L] <br />SAN JOAQUIN COUNTY <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 />I� 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 Name Shell - Lodi "PLAZA LIQUORS" <br />Phone # <br />I <br />L <br />Address 2420 W Turner Rd Lodi 95242 <br />TCross <br />Street <br />Y <br />Owner/Operator Tom Graves <br />Phone # <br />C <br />Contractor Name HMC - Henderson Maintenance Company <br />Phone # (209) 467-7573 <br />N <br />T <br />Contractor Address PO Box 31325 - Stockton, CA 95213 <br />CA Lic # 856771 Class D21 / D40 <br />A <br />Insurer State Fund <br />Work Comp # 1908193 <br />T <br />ICC Technician's Name Carl Wayne Henderson / 5252923 -UT <br />Expiration Date 8/10/10 <br />Q <br />R <br />ICC Installer's Name N/A <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(ee Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date 6 a <br />APPLICANT MUST PERFORM ALL W K IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENT L 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: "1 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 />7 <br />Applicant's Signature 11— - d ` Title Contractor Date iy -Z 8 <br />bILLINU INI-UKMA I IUN: <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 W Henderson TITLE Contractor PHONE # (209) 467-7573 <br />ADDRESS PO Box 31325 - Stockton, CA 95213 <br />SIGNATURE e--- - ` DATE /'0 <br />EH230038 (revised 02/20/09) <br />1 <br />