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10 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 /> TFf PERV Ef jySgO CDIJ et OM 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# <br /> � Facility Name CRLLC # 2705447 Phone# <br /> I Address 1469 E. Hammer Lane <br /> L <br /> TCross Street West Lane <br /> Y Owner/Operator Convenience Retailers, LLC Phone# <br /> C Contractor Name Walton Engineering, Inc. Phone#(916) 373-1152 <br /> 0 <br /> N Contractor Address P.O. Box 1025 CALic#617238 ClassA B HazMa <br /> T <br /> R Insurer Work Comp# <br /> A Praetorian Insurance WC4000674 <br /> T ICC Technician's Name Expiration Date <br /> T see attached p� 10/01/12 <br /> 0 ICC Installer's Name Expiration Date <br /> R see attached <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T 91 UST direct-bury Spill container <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N <br /> Plan Reviewers Name Dates <br /> APPLICANT MUST PERFORM ALL W RK 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." A q� <br /> Applicant's Signature_ v,► N/! L Title Date 05-02-12 <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 Tanya Thompson TITLE PHONE# 916 373-1165 <br /> ADDRESS PO Box 1025, West Sacramento, CA 95691 <br /> SIGNATURE 3 j/1V-nvy-�_-DATE 05-02-12 <br /> EH230038(revised 02/2( <br /> 1 <br />