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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 600 East Main Street, Stockton, California 95202 Telephone: (209) 468-3420 Fax: (209) 468-3433 APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: P TANK RETROFIT ❑ PIPING REPAIR/RETROFIT XUDC REPAIR/RETROFIT XCOLD START/EVR UPGRADE BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAME KIMBERLY MILLS c/o LOVE's TITLE PHONE# (405) 687-1060 COUNTRY STORES OF CALIF. ADDRESS 10601 N. PENNSYLVANIA AVE., OKLAHOMA CITY, OK 73120 SIGNATURE DATE EH230038 (revised 08/1/11) 2 Project Contact & Telephone # JR BEARD 805 540-5240 F EPA Site # C Facility Name LOVE'S TRAVEL STOP #223 Phone # (209) 599-5648 1 Address 1553 COLONY ROAD, RIPON, CA 95366 L I Cross Street JACK TONE ROAD T Y Owner/Operator KIMBERLY MILLS Phone # 405-687-1060 C Contractor Name FILLNER CONSTRUCTION Phone # ( 916) 624-1985 N THie Contractor Address 4470 YANKEE HILL RD. ROCKLIN CA Lic # 177928 Class BA, HAZ, C10 A Insurer TRAVELER Work Comp # 1TR821C)XZ,-11TTT 11 T ICC Technician's Name NAHUM VALDEZ Expiration Date 6/28/2013 ° ICC Installer's Name NAHUM V DEZ Expiration Date 6/28/2013 Tank system work area Tank Size Chemicals Stored Currently Date UST (i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed T A N K P ❑ Approved, Approved with conditions — Disapproved L (See Attachment With Conditions) N Plan Reviewers Name I" i' �� l«� Date APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN 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 TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." / PZ! kfGI PAA- 3(Z L div Applicant's Signature Title Date BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAME KIMBERLY MILLS c/o LOVE's TITLE PHONE# (405) 687-1060 COUNTRY STORES OF CALIF. ADDRESS 10601 N. PENNSYLVANIA AVE., OKLAHOMA CITY, OK 73120 SIGNATURE DATE EH230038 (revised 08/1/11) 2