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9 01 <br />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 <br />EPA Site # <br />Project Contact & Telephone #Dul c inea C. 916-373-1166 <br />A <br />� <br />Facility Name CRLLC #2705448 <br />Phone# 209-957-2900 <br />I <br />L <br />Address 3202 W. Hammer Lane <br />1 <br />T <br />Cross Street <br />Y <br />Owner/Operator Pacific Convenience and Fuels, LLC <br />Phone # 2 0 9 - 95 7 - 2 9 0 0 <br />C <br />Contractor Name Walton Engineering, Inc <br />Phone # 916-373-1166 <br />0 <br />N <br />Contractor Address P.O. Box 1025 <br />CA Lic # 617238 Class A, B Ha z <br />T <br />R <br />A <br />Insurer State Fund <br />Work Comp# BB1093003 <br />TICC <br />Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <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 />UDC 1/2 <br />10 K <br />87 - Gasoline <br />T <br />A <br />UDC 7/8 <br />10 K <br />91 - Gasoline <br />N <br />K <br />P <br />❑ Approved �pproved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Na Date •-/F,o <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 <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 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 Covan TITLE`✓Ompliance Manager PHONE# 916-373-1166 <br />ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br />SIGNATURE �/�— DATE <br />EH230038 (revised 02/20/09) <br />1 <br />