Laserfiche WebLink
7' r <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAUIN 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 EPA Site# Project Contact&Telephone ADul c inea Covan916-3 7 3-116 6 <br /> A <br /> C Facility Name Quik Stop #121 Phone# 510-657-8500 <br /> 1 Address 1196 W. Louise Avenue <br /> L <br /> TCross Street N. Union Road <br /> Y Owner/Operator Quik Stop Markets Phone# 510-657-8500 <br /> C Contractor Name Walton Engineering, Inc. Phone# 916-372-1888 <br /> O <br /> N Contractor Address P.O. Box 10 2 5CA Lic# 617238 Class HAZ A, B <br /> T <br /> R <br /> A Insurer State Fund Work Comp# BB1103003 <br /> C <br /> T ICC Technician's Name Expiration Date <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T #1 12 K Gasoline - 87 <br /> A #2 12 K Gasoline - 89 <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Atttachpment With Conditions) <br /> A <br /> N Plan Reviewers Name /Date /0 L <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 AGENTS 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 Signat re Title Date `� 0 <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 Dul c inea Covan TITLECOmpl iance Manager PHONE# 916-373-1166 <br /> ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br /> SIGNATURE DATE `l <br /> EH230038(revised 9) <br /> 1 <br />