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4 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 [3 COLD START/1MRAWAM&M <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />Facility Name QuikStop # 132 <br />Phone# <br />I <br />L <br />Address 3555 West Hammer Lane, Stockton, CA 95219 <br />TCross <br />Street <br />Y <br />Owner/Operator Quik Stop Markets, Inc. <br />Phone# (510) 657-8500 <br />o <br />Contractor Name Walton Engineering, Inc. <br />Phone # ( 916) 373-1165 <br />N <br />T <br />Contractor Address P.O. Box 1025, West Sac <br />CALic# 617238 Class A, B, Haz <br />A <br />Insurer Sea Bright <br />Work Comp# BB1093003 <br />T <br />ICC Technician's Name see attached certifications <br />Expiration Date <br />° <br />R <br />ICC Installer's Name see attached certifications <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T <br />No Change <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />n 99 <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WO 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 <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." jtla" t ��P- - jq t //j Date �6 <br />1Applicant's <br />Signature Title ,( C <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 parry 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 / �? . TITLE PHONE # c! 3 <br />ADDRESS x s l� <�. d VlQ s2 i? j ( <br />EH230038 (revised 02/20/09) <br />1 <br />viat <br />