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ENVIRONINiL.:'NTAL HEALTH DEr"ARTMENT <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 <br />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 29 UDC REPAIR/RETROFIT [RCOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Veronica 916-373-1167 <br />A <br />C <br />Facility Name California Gas Station, LLC <br />Phone# <br />I <br />Address 1399 E. Yosemite Ave., Manteca, CA 95336 <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator Ted Guzman <br />Phone # <br />o <br />Contractor Name Walton Engineering, Inc. <br />Phone # 916-373-1167 <br />N <br />T <br />Contractor Address P.O. Box 1025, W. Sacramento <br />CA Lic # 617238 ClassA B Haz <br />A <br />InsurerQBE Insurance Corp <br />Work Comp# QWC4000647 <br />TICC <br />Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved 1�1fApproved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />I <br />Plan Reviewers Name JV ,4 ii 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 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 />Applicant's Signature.A 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 -Walton Engineering, Inc. TITLE Contractor PHONE# 916-373-1167 <br />ADDRESS <br />SIGNA <br />EH230038 (revised 08/1/11) <br />2 <br />III!• 1WFAMMAPIN <br />