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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 REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name Circle-K #2701205 Phone# 209-858-4116 <br /> 1Address 16470 Cambridge Drive <br /> L <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Circle K Phone# 209-858-4119-- <br /> 0 <br /> c Contractor Name wal ton Engineering, Inc . Phone# 916-372-1888 <br /> NContractor Address Commerce rive CALic# 617238 kLAZ A, 8 <br /> Class <br /> T <br /> R Insurer State Fund Work Comp#BB1103003 <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored CurrenDate UST <br /> 0.e.87 pip V p,e1 lek detr,UDC 112, y <br /> Installed <br /> T Gasoline 87 Unknown <br /> A Gasoline 91 Unknown <br /> N <br /> K <br /> P ❑ Approved KApproved with conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name Date�'a-� I <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 <br /> TO 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^ ( 1 <br /> Appliraffs Signa Title [„�. Date -y- <br /> BILLING INMATION: <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 Covan TITLE Compliance Manage�HONE# 916-373-1166 <br /> ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br /> SIGNATURE G� - DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />