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A Il <br />1 <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 />A <br />EPA Site # <br />Project Contact & Telephone # Dul cinea Webb916 - 3 73 -1166 <br />C <br />Facility Name Quik Stop ##144 <br />Phone# 510-657-8500 <br />I <br />L <br />Address 7272 West Lane <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator Quik Stop Markets <br />Phone# 510-657-8500- <br />C <br />Contractor Name Walton Engineering, Inc. <br />Phone # 916-372-1888 <br />T <br />Contractor Address P.O. Box 1025 <br />CA Lic # 617238 Class H.AZ A, B <br />RInsurer <br />A <br />State Fund <br />Work Comp# 713-4927-2008 <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />#1 <br />10 K <br />Gasoline - 87 <br />A <br />#2 <br />10 K <br />Gasoline - 89 <br />N <br />K <br />#3 <br />8 K <br />Gasoline - 91 <br />P <br />❑ Approved ❑ Approved with conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name 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, 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 �1 Title CS�eC.wee <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 Webb TITLE Compliance Manager -HONE# 916-373-1166 <br />P.O. Box 1025, West Sacramento, CA 95691 <br />SIGNATURE ) <br />EH230038 (revised 02/20/09) <br />1 <br />TE 9 -'OAA-0q <br />