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ENVIRONMENTAL HEALTH DEPARTMENT <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 /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name AGP-GREWALS GAS &LIQUOR Phone# 209 463-5294 <br /> 1 Address 4100 E Fremont St Stockton 95215 <br /> L <br /> Cross Street <br /> T <br /> Y Owner/Operator Rick Grewal Phone#/209 463-5294 <br /> C Contractor Name Service Station Testing-SST INC Phor*## (209)465-5577 <br /> 0 <br /> N Contractor Address PO Box 31465-Stockton, CA 95213 CA Lic# ,.1162520 Class A/B/C-10,20,36 <br /> T <br /> A Insurer EXEMPT Work Comp# N/A <br /> T ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 08/10/2014 <br /> Q <br /> R ICC Installer's Name N/A Expiration Date N/A <br /> Tank system work area Tank Size j6hemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> f <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ;(S Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANICE4NITH 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, ERMIT 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 CH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." t' <br /> Applicant's Signature ` Title Authorized Agent Data 6/12/14 <br /> BILLING INFORMATION: <br /> Indicate the responsible party to b billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is ifferent than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by s' nature and date below. <br /> NAME Carl Wayne enderson TITLE President PHONE# (209)467-7573 <br /> e <br /> ADDRESS �PO' Box,81325-Stockton, CA 95213 <br /> SIGNATURE DATE 6/12/14 <br /> EH230038(revised,1 <br /> 02/20/09) <br /> 1 <br />