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SANJOAQUIN Environmental Health Department <br /> -- COUNTY - <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 ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Kristin Na en/916-373- 1165 <br /> A <br /> C Facility Name S eedwa # 4492 Phone # 209467-3918 <br /> 1 Address <br /> L 2132 Mariposa Road , Stockton CA 95205 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Phone # <br /> C Contractor Name Walton Engineeing , Inc. Phone # 916-373- 1165 <br /> N Contractor Address CA Lic # 617238 Class <br /> T P . O . Box 1025 g Haz <br /> AInsurer Attached Work Comp # <br /> cICC Technician ' s Name <br /> T Rafael Flores Expiration Date 3-20-2019 <br /> o ICC Installer's Name Expiration Date 2-14-2019 <br /> R Rafael Flores p � <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 (S ttachment With Conditions ) <br /> A <br /> N Plan Reviewers Name Date 2 / 7 <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 E F 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 000/ <br /> Title Contractor Date 7- 15-19 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Kristin Nappen TITLE Construction Administrator PHONE # 916-373-1165 <br /> ADDRESS P . O . Box 1OZ5 West Sacramento , CA 95691 <br /> SIGNATURE DATE 7- 15- 19 <br /> 2 of 6 <br />