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Environmental Health Department <br /> S A Wij0AQUIN <br /> - COU NTY --- -- <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 /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Veronica Freitas 916 - 373 - 1166 <br /> A <br /> C Facility Name Colonial Energy #40138 Phone # <br /> 1 Address 14000 E . Hwy 88 <br /> L <br /> I Cross Street <br /> f Y Owner/Operator Colonial Energy , LLC Phone # 916 -285 -7402 <br /> C Contractor Name Phone # 916 - 373 - 1166 <br /> o Walton Engineering, Inc . <br /> N Contractor Address p , 0 . Box 1025 , West Sacramento , CA 95691 CA Lic # 617238 Class ABHaz <br /> T Work Comp # <br /> R Insurer <br /> A See Attached Expiration Date 05 - 13 - 20 <br /> C ICC Technician ' s Name Curtis Carpenter <br /> T <br /> o Expiration Date <br /> R ICC Installer's Name <br /> Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) <br /> T 91 STP Sum <br /> A UDC # 1 -2 <br /> N <br /> K <br /> P ❑ Approved ►L�Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) Q c� <br /> A Date t 1 <br /> N Plan Reviewers Name <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 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 1 / Title Com 1i nce M n er Date <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant , e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Wilton Engin =r , Tnc TITLE C nntrnrtnr PHONE <br /> ADDRESS 102q , WCSt SacramenfoCA 99691 C( <br /> / f <br /> DATE ! �� <br /> SIGNATURE AAA <br /> 2of6 <br />