Laserfiche WebLink
ENVIRONML-NTAL HEALTH DbOARTMENT <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 REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Dulc inea Webb 916-373-1166 <br /> A <br /> C Facility Name Circle K #2701205 Phone# 209-858-4116 <br /> � Address 16470 Cambridge Drive <br /> I Cross Street <br /> T <br /> Y Owner/Operator Circle K Phone# 209-858-4116 <br /> C Contractor Name Walton Engineering, Inc. I Phone# 916-372-1888 <br /> N Contractor Address 3900 Commerce Drive CALic# 617238 Class HAZ A, B <br /> T <br /> A Insurer State Fund Work Comp# 713-4927-2008 <br /> T ICC Technician's Certification Number Expiration Date <br /> U <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Cu rrently/Previously <br /> T Gasoline 87 Unknown <br /> A Gasoline 91 Unknown <br /> N <br /> K <br /> P ❑Approved ❑Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <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 AGENTS 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 LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THEP MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNI .' 2 <br /> Applicants Sign ure Title Date <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 Dulcinea Webb TITLE Compliance ManagerpHONE# 916-373-1166 <br /> ADDRESS P.O. BOX 1025, West Sacramento, CA 95691 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />