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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />'M <br />X 6 <br />a ' * <br />r_•1111imKIP-M, 14-11;z6f, Will= iRM � <br />sk 0i '34 ro 10 <br />�:4:49N* 'Ilk <br />:E 4:14. <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />11 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT XCOLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact& Telephone #Veronica 916-373-1167 <br />C <br />1 <br />Facility Name Quik St02 #076 <br />Phone #209- 948 -673 1 <br />1 <br />L <br />Address S. Olive Avenue, Stockton, CA 95215 <br />1 <br />T <br />Cross Street P -Main st-rimpt <br />Y <br />Owner/Operator uik Stop Markets. Ing. Phone# 510-657-8500 <br />C <br />Contractor Name <br />amewall-nn Enalnee-ring, Inc,_ Phone # 916-373-1167 <br />Ph, <br />N <br />T <br />R <br />Contractor Address P.O. Box 1025, W.Sac mento <br />CA Lic # lass A B Haz <br />1 <br />617238 C <br />A <br />C <br />insurer QBE Insurance Corp. <br />Work Comp #QWC4000674 <br />T <br />0 <br />ICC Technician's Name See Attached <br />Expiration Date <br />R_ <br />ICC Installers Name See Attached <br />Expiration Date <br />Tank system work area <br />(i.e. BY piping Bump, 91 leak detector, UDC 112. etc.) <br />Tank Size Chemicals Stored Currently Date UST <br />Installed <br />T <br />87 Spill rnnt-=.jner <br />12,000 ingz <br />A <br />N <br />K <br />P <br />L <br />Approved Approved with conditions Disapproved <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name/Date_­7 3 <br />I <br />APPLICANT MUST PERFORM ALL IN ACCORDANCE WITH SAN CO ORDINANCES. STATE LAWS, AND RULES AND RULAT ONS OF N <br />JOAQUIN COUNTY, ENVIRONMENTALWORK HEALTH DEPARTMENT. OWNER OROEGIC <br />LICENSED AGENT$ <br />SIGNATURE CERTIFIES THE FOLLOWING: .1 CERTIFY THATSAIN <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 <br />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." I / - <br />Applicant's Signature —ZkZ19"r-1 <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 Encrinearincr. Tn TITL -PHONE #-A-1-6 -17 -A.- 119 7 <br />EH230038 (revised 10/30/12) <br />2 <br />M <br />