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4X20D.1 66-1I <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> O TANK RETROFIT ❑PIPING REPAIRIRETROFIT XUDC REPAIR/RETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# CAL000412499 Project Contact&Telephone# Angel Rodriguez 916-373-1165 <br /> A <br /> C Facility Name Colonial Energy#40135 Phone# 714-448-5000 <br /> Address L Add192 Lathrop Rd.Lathrop,CA 95330 <br /> TCross Street <br /> Y Owner/Operator Colonial Energy,LLC Phone# 714-761-5426 <br /> c <br /> 0 Contractor Name Walton Engineering,Inc. Phone# 916-373-1165 <br /> N Contractor Address P.O.Box 1025 West Sacramento CA 95691 CA Lic#617238 Class AB HAZ <br /> T <br /> A Insurer State Compensation Insurance Fund Work Comp# 9113339-2017 <br /> cICC Technicians Name David Delgado-5246959 <br /> T ' 8 Expiration Date 12-29-2019 <br /> R ICC Installer's Name David Delgado-5246959 1 Expiration Date 9-24-2018 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> I.e.87 piping sump,91 leak tletaotee UDC In.etc.) y Installed <br /> T All 12 UDC's at Dispensers, <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L mt <br /> achment With Conditions) <br /> A Q <br /> N 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 TO <br /> WORKER'S COMPENSATION LA OF CALIFORNIA." NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF HE WORK FOR WHI THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> '^ <br /> AppliwnYs Signature-14&5 Title 1 e5 1�2�t Date 1/2-S/5 I <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. f <br /> NAME MtryiC,QI WC.I+OYI TITLE )9rC5:j-i PHONE# [1 <br /> ADDRESS ) ,04,-y IC92 S We-- t- CA -ISGq� <br /> SIGNATURE DATE IlzS1 I$ <br /> EH230038(revised 7-26-2016) 2 <br />