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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 L3 COLD START/_ZXltAk0AWA[W <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name QuikStop # 125 Phone# (510) 657-8500 <br /> 1 Address 1580 West Main Street, Ripon, CA 95366 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Quik Stop Markets, Inc . Phone# (510) 657-8500 <br /> C Contractor Name Walton Engineering, Inc . Phone# (916) 373-1165 <br /> 0 <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# BB1093003 <br /> T ICC Technician's Name see attached certifications Expiration Date <br /> 0 <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 / U <br /> N Plan Reviewers Name d`'� rub DateT <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 SignatureJ ''^ ✓ Title "�� Ao��/ `bateZ-� <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 �(,� �G� 0 � �� -TITLE PHONE# (VI3 7� G,,S <br /> ADDRESS <br /> West, _V vcLm e►jk (A 960 <br /> SIGNATURE �, �u� J/ �� DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />