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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 /> TFf PERy Ei2113ESg0 DAYS FtROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � <br /> Facility Name CRLLC # 2705448 Phone# <br /> 1 Address 3202 W. Hammer Lane <br /> L <br /> I Cross Street Kelley Drive <br /> Y Owner/Operator Convenience Retailers, LLC Phone# <br /> C Contractor Name Wal ton Engineering, Inc. <br /> 0 Phone#(916) 373-1152 <br /> T Contractor Address P.O. Box 1025 CA LiC#617 2 3 8 Class A B Ha zMa <br /> A Insurer SeaBright WorkCOmp#BB1093003 <br /> T ICC Technician's Name see attached Expiration Date 10/01/11 <br /> R ICC Installer's Name see attached Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T 87 - Spill Container 11K gal <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with Conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A ®®// <br /> N Plan Reviewers Name4�A, Date-2, '<bf <br /> APPLICANT MUST PERFORM ALL VAK 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." <br /> Applicant's Signature_ �" j�� �— Title Date 02-16-11 <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 Tanya Thompson TITLE PHONE# 916 373-1165 <br /> ADDRESS PO Box 1025, West Sacramento, CA 95691 <br /> SIGNATURE 1 02-16-11 <br /> EH230038(revised 02/2( <br /> 1 <br />