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T <br /> 1 <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 /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT C3 COLD START/kXRXJBG&qM <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name QuikStop 4 121 Phone# (510) 657-8500 <br /> 1 Address 1196 West Louise Avenue, Manteca, CA 95336 <br /> L <br /> TCross Street <br /> Y Owner/Operator Quik Stop Markets, Inc. Phone# (510) 657-8500 <br /> C Contractor Name Walton Engineering, Inc . Phone# (916) 373-1165 <br /> O <br /> N Contractor Address P.O. Box 1025, West Sac CALic# 617238 Class A, B, Haz at <br /> T <br /> A Insurer Sea Bright Work Comp# BB1093 003 <br /> T ICC Technician's Name see attached certifications Expiration Date <br /> Q <br /> R ICC Installer's Name see attached certifications 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 No Change <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A G <br /> N Plan Reviewers Name Date <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 <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 Signature �� .:9�''�` /� ��'' � "� Title <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 /> responsi�for the billing b signature and date below. <br /> NAME �ITITLE PHONE# 0� / 373- !1L'"s <br /> ADDRESS �: , �. Ld� C/ <br /> SIGNATURE �2 �j L �-'— DATE r3 <br /> EH230038(revised 02/20/09) <br /> 1 <br />