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0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT XCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Veronica 916-373-1167 <br /> A <br /> O Facility Name Quik Sto2 ##076 Phone#209-948-6731 <br /> 1 Address <br /> 1030 1030 S. Olive Avenue Stockton CA 95215 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator uik stop M rkets Inc. Phone#510-657-8500 <br /> CContractor Name <br /> ° Phone# 916-373-1167 <br /> N Contractor Address <br /> T P.O. Box 1025 W,Sacramento CALX# 617238 Class B Haz <br /> R Insurer <br /> A QBE Insurance Corp. Work COmp#QWC4000674 <br /> C ICC Technician's Name <br /> See Attached Expiration Date <br /> R° ICC Installers Name <br /> 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 v2,etaemcas <br /> ) Installed <br /> T 12 000 <br /> A <br /> N <br /> K <br /> P Approved <br /> L Approved with conditions Disapproved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> Date <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,1 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 FOLLOWIN <br /> THAT IN THE PERFORM G: "I CER7tFY <br /> CE 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 Tltte rnns t r Qn �Q r .Date7- 2- <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 TITLE(n��` n_ rc�CtPHONE# <br /> ADDRESS P.O. Box. 1025 West Sacramento CA 95691 <br /> r <br /> SIGNATURE ' DATE a 7__L3 3_ <br /> EH230038(revised 10/30/12) <br /> 2 <br />