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J <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 13 COLD START/jWRXXNXVAW <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name QuikStop # 144 <br /> Phone# (510) 657-8500 <br /> 1 Address 7272 West Lane, Stockton, CA 95210 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Quik Stop Markets, Inc. Phone# (510) 657-8500 <br /> c Contractor Name Walton Engineering, Inc . Phone# (916) 373-1165 <br /> T Contractor Address P.O. Box 1025, West Sac CALic# 617238 Class A, B, Haz at <br /> A Insurer Sea Bright Work Comp# BB1093003 <br /> T ICC Technician's Name see attached certifications Expiration Date <br /> R ICC Installer's Name see attached certifications 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 No Change <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 Name Date--,!5v <br /> APPLICANT MUST PERFORM ALL WORK[It/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 PERFORMAN E OF JHE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature l � Title _ / w 0/ Date Z-)"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 /> responsibiljty for the billing y signature and date below. <br /> NAME 6 k7b,,J E TITLE PHONE# (2/0 3 73" jI <br /> ADDRESS �. Q, <br /> SIGNATURE 1j. DATE Y,23Q <br /> EH230038(revised 02/20/09) <br /> 1 <br />