Laserfiche WebLink
ENVIRONMENTAL <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 REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />EPA Site # <br />Facility Name Tulare Farms, LLLP (was <br />Address 2771 E Frencl <br />Cross Street <br />Owner/Operator Tulare Farms, LLLP <br />Contractor Name Service Station Testin <br />Contractor Address PO Box 31465 - Stc <br />Insurer EXEMPT <br />ICC Technician's Name Carl Wayne Hend, <br />ICC installer's Name <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />❑ Approved <br />Project Contact &Telephone # <br />Ace Tomato) <br />Phone # 209 235-3055 <br />i Camp Rd <br />Manteca 95336 <br />Phone # 209 235-3055 <br />g -SST INC <br />Ickton, CA 95213 CA Lic # <br />Phone # (209) 465-5577 <br />962520 Class A /B / C-10,20,36 <br />Work Comp # N/A <br />arson (5252923) Expiration Date Og/10/2014 <br />N/A Expiration Date N/A <br />Date UST <br />Tank Size Chemicals Stored Currently Installed <br />❑ Approved with conditions ❑ Disapproved <br />(See Attachment With Conditions) <br />Date <br />Plan Reviewers Name <br />APPLICAT MUST PERFORM ALL NCES, STATE <br />AND RULES AND REGULATIONS <br />OAO NNCOUNTY, ENV RONMENTTAALRHEALTHCDEPARTMENTTOWNER OROLICENSED GENTS SIGNATURE CERTI LAWS, O <br />S THE FOLLOWING: "I CERTIFY THATIN <br />NNER AS TO BECOME SUBJECT <br />TTHE O WORKER'S COMPENSATIONOLAWS OF FORRK CALIFORNIA." ICH THIS CONTRACTOR'S HIRING OR SUBCONTRACTING S GNATURE CERTIFRMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A IES THE FOLLLOW1NG: "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 />p ent Date 8/14/13 <br />rale Authorized Ag <br />Applicant's Signature �-�` i^�" <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit the party muyment st acknowledgeage per ank. If <br />the party designated below is different than the permit applicant, e. properly <br />responsibility for the billing by signature and date below. <br />NAME Carl Wayne Henderson TITLE <br />President PHONE # (209) 467-7573 <br />ADDRESS PO Box 31325 - Stockton, CA 95213 <br />SIGNATURE %.,.__. <br />EH230038 (revised 02/20/09) <br />1 <br />TE 8/14/13 <br />