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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 <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 INCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Veronica 916-373-1167 <br /> A <br /> C Facility Name Quik Stop #125 Phone# 209-599-4261 <br /> I Address 1580 W. Main Street, Ripon, CA 95366 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator uik Stop Markets LLC Phone# <br /> C Contractor Name Phone# <br /> 0 916-373-1167 <br /> T Contractor p.0. Box 1025 W. Sacramento CALic#617238 ClassA B Haz <br /> A m Insurer BE Insurance Coan Work Comp# WC4000674 <br /> T ICC Technician's Name see attached Expiration Date 10/1/13 <br /> R ' Expiration Date <br /> ICC Installers Name 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 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name A1*D- - Date�Zt (� <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 PERFORMA 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 Title COn ra _t Or Date 12/7/12 <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 /> NAMEVeroni ca Freitas TITLE contractor PHONE# 916-373-1167 <br /> ADDRESS,P-0. Fjnx 1165 , West Sacramento, CA gSegl <br /> SIGNATURE a DATE 12/7/12 <br /> EH230038(revised 08/1/11) <br /> 2 <br />