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ENVIRONMATAL 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 AOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone #Dul c inea Webb 916-373-1166 <br />A <br />C <br />Facility Name Quik Stop #132 <br />Phone # 510-657-8500 <br />I <br />L <br />Address 3555 W. Hammer Lane <br />TCross <br />Street Mariners <br />Y <br />Owner/Operator Quik Stop Markets <br />Phone # 510-657-8500 <br />o <br />Contractor Name Walton Engineering, Inc. <br />Phone # 916-372-1888 <br />N <br />T <br />Contractor Address 3900 Commerce Drive <br />CALic# 617238 Class HAZ A, B <br />A <br />Insurer State Fund <br />Work Comp# 713-4927-2008 <br />TICC <br />Technician's Certification Number <br />Expiration Date <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Date UST Installed <br />Currently/Previously <br />#1 <br />12 K <br />Gasoline - 87 <br />T <br />A <br />#2 <br />12 K <br />Gasoline - 89 <br />N <br />K <br />#3 <br />12 K <br />Gasoline - 91 <br />P <br />,- A proved ❑Approved with conditions ❑Disapproved <br />L <br />See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Nam Date C� <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 />Applicants Signature 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 />P.O. Box 1025, West Sacramento, CA 95691 <br />SIGNATU <br />EH230038 (revised 12/31/07) <br />1 <br />