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w <br /> 0 1 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 <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 N UDC REPAIR/RETROFIT N COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Veronica 916-373-1167 <br /> A <br /> O Facility Name Quik Stop Market #152 Phone# 209-369-7375 <br /> I <br /> L Address 1721 S . Cherokee Ln. <br /> TCross Street <br /> Y Owner/Operator Quik Stop Markets, Inc . Phone# <br /> C Contractor Name Walton Engineering, Inc . Phone# 916-373-1167 <br /> T Contractor Address P.O. Box 1025, W. Sac 95691 CALic# 617238 Class B Haz <br /> A Insurer praetorian Insurance Company Work Comp#QWC4000674 <br /> TICC Technician's Name Expiration Date <br /> RICC 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 #2 91 Product Tank 10K 89 Gasoline no change <br /> A 43 Diesel Product Tank 8K 91 Gasoline no change <br /> N <br /> K <br /> P ❑ Approved Approved with conditions El Disapproved <br /> L e Attac eFrt ith Conditions) <br /> A <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 TO <br /> 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." fl, <br /> v � <br /> Applicant's Signature Lite r. Cf °$= " TitleWalton Engineerinq Date 9/4/2012 <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 /> NAMEWalton Engineering, Inc . TITLE Contractor PHONE#916-373-1167 <br /> ADDRESSP.O. Box 1025 West Sacramento CA 95691 <br /> SIGNATURE --DATE-c)/4/2 n l <br /> EH230038(revised 08/1/11) <br /> 2 <br />