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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 <br />EPA Site # <br />Project Contact & Telephone JDul c inea Covan916 - 3 7 3 -116 6 <br />A <br />C <br />Facility Name Market Place Phone# 209-478-5504 <br />1 <br />Address 4405 Pacific Avenue <br />L <br />TCross <br />Street <br />Y <br />Owner/Operator Pacific Car Wash <br />Phone# 209-478-5504 <br />C <br />Contractor Name Walton Engineering, Inc. <br />Phone# 916-372-1888 <br />N <br />T <br />Contractor Address P.O. Box 1025 <br />CA Lic # 617238 Class HAZ A, B <br />A <br />Insurer State Fund <br />Work Comp# BB1103003 <br />T <br />ICC Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />#1/2 <br />Unknown <br />Gasoline - 87/91 <br />T <br />A <br />N <br />K <br />P <br />❑ Approved proved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Nam Date <br />APPLICANT MUST PERFORM ALL ORK 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 />.... � <br />Applicant's Sign 're Title v \®C1V\jDate ; <br />BILLING INFORMATION: <br />Indicate the responsible parry 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 TITLE Compliance Manage&ONE # 916-373-1166 <br />ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br />SIGNATUf <br />EH230038 <br />1 <br />TE <br />