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Ell <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT 5d PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Veronica Freitas 916-373-1167 <br />� <br />Facility NamePhone <br /># <br />L <br />Address 1403 CniintrV Club Blyd.,Storkton, CA 95204 <br />T <br />Cross Street N. Pershing Ave. <br />Y <br />Owner/Operator Pacific Convenience and Fuels, LLC <br />Phone # <br />cContractor <br />Name <br />Phone # <br />0Walton <br />Enginering, Inc. <br />N <br />Contractor Address <br />CA Lic # Class <br />TWestSacrament <br />617238 <br />R <br />A <br />Insurer <br />Work Comp # <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />o <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T <br />Diesel Secondaq Line <br />A <br />N <br />K <br />P <br />❑ Approved pproved with conditions ❑ Disapproved <br />L(See <br />chment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL W K 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 TO <br />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 Title Const. Coordinator Date 11/14/13 <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 parry must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME Walton Fri—gine�eri�nu, Inc_ TITLE Contractor PHONE# 916-373-1167 <br />ADDRESS P.O. Box 1025 West Sacramento CA 95691 <br />SIGNATURE A"45� DATE 11-14-13 <br />EH230038 (revised 10/30/12) <br />