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02/07/2014 10:41 91637311 WALTONENGINEERIIib PAGE 03/09 <br />"i �„ M" 4 , lr <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 PERMITTYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Veronica Freitas 916.373.1167 <br />A <br />O <br />Faclllty Name Tower Mart # 104 Phone it, 209-858-4998 <br />� <br />Address 192 Lathrop Road, Lathrop, CA 95330 <br />1 <br />T <br />Cross Street Cambrid a Dr. <br />Y <br />Owner/Operator Tower Energy GroupPhone <br /># <br />OContractor <br />o <br />Name Walton Engineering, Inc. <br />Phone # 916-373-1167 <br />T <br />Contractor Address P.O. Box 1025, West Sacramento, CA 95691 <br />CA Lic #617238 Class A,B,Idaz <br />A <br />Insurer BE Insurance CoT. <br />Work Comp # WC4000674 <br />T <br />ICC Technician's Name Robert Bush <br />Expiration Date <br />q <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />II.e.9]plpMQ8UMp,et Cdkdateddr,UDC IM.dlc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date T <br />Id <br />T <br />Diesel STP Sensor <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(Se Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date CJy�a / `P <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING; "I CERTIFY THAT IN <br />THE PERFORMANCE OFTHE 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 LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "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 />AppflmnVo91 nature ' CJik�- TIne Const. Coord. Dat. 01/27/2014 <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. <br />NAME Veronica Freitas TITLE Const. Coord. PHONEIP 916-373-1167 <br />ADDRESS P.O i30x 10 A. WOO iacramento. CA_ 9569 _ <br />SIGNATURE 9AS. DATE_ 01127/2014 <br />EH230038 (revised 10/30/17) <br />2 <br />Received Time Feb. 1. 2014 9:50AM No -5150 <br />