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0 • <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 />TV PERV Ei�If3ES180 CD et OM 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 # <br />A <br />C <br />Facility Name CRLLC # 2705446 <br />Phone# <br />I <br />L <br />Address 1403 Country Club Boulevard <br />I <br />Cross Street North Pershing Avenue <br />T <br />Y <br />Owner/Operator Convenience Retailers, LLC <br />Phone # <br />C <br />Contractor Name Walton Engineering, Inc. <br />Phone # ( 916) 373-1152 <br />O <br />N <br />T <br />Contractor Address P.O. Box 1025 <br />CALic#617238 ClassA B HazMa <br />RInsurer <br />A <br />Praetorian Insurance <br />Work Comp # WC4000674 <br />C <br />T <br />ICC Technician's Name see attached <br />Expiration Date <br />p� 10/01/12 <br />Q <br />R <br />ICC Installer's Name see attached <br />Expiration Date <br />p <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />Waste Oil Piping Sump Sensor <br />A <br />N <br />Diesel STP Relay <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />) <br />Plan Reviewers Name z< Date S/ 7-5�� 1 Y <br />APPLICANT MUST PERFORM ALL WO 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 CALIFO IA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />{//�/,1 <br />Applicant's Signature_ 3 (-' "1� iVk-,-- Date 05-21-12 <br />BILLING INFUKMA I IUN: <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 Tanya Thompson TITLE PHONE # 916 373-1165 <br />ADDRESS PO BOX 1025, <br />SIGNATURE 3 J) <br />EH230038 (revised 02/2( <br />West Sacrament D, CA 95691 <br />A. <br />1 <br />TE 05-21-12 <br />