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05/04/2009 13:17 9163731173 WALTONENGINEERING PAGE 03 <br /> 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 REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# I Project Contact&Telephone# <br /> A Circle K 2701205 209-858-4116 <br /> C Fac lity Name Phone# <br /> I <br /> L Address 16470 Cambridge Drive <br /> TCross Street <br /> Y Owner/Operator Circle K Phone III 209-858- 1 <br /> cContractor NameWa toll Engineering, Inc. -372-188B <br /> G Phone# <br /> N Contractor AddreSS orlvr(erce rive CALic# 617238 RAZ A, H <br /> Class <br /> T <br /> A Insurer State Fund Work Comp#713-4927-2008 <br /> T ICC Technician's Name Expiration Date <br /> D ICC Installers Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (I.e.In MP„9 a P.91 IMk a,nae ..UDC IQ,MAI Installed <br /> T Gasoline 87 Unknown <br /> A Gasoline 91 Unknown <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S Attachment With Conditions) <br /> A �J <br /> N Plan Reviewers Name-61w� 6 Date ��U / <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LANG,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT,OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA," CONTRACTOR'S MIRING 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 /> Applimt s 3lgnawre Title Dare <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EMD 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 Dulcinea Webb TILACompliance ManagerPHONEe 916-373-1166 <br /> ADDRESS P.O. Sox 1025, West Sacramento, CA 95691 <br /> l <br /> SIGNATOR ATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />