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SANJOAQUIN Environmental Health Department <br /> C0U N T Y <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 N PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Veronica Freitas 916 -373 - 1166 <br /> C Facility Name Charter Way 76 Phone # 209227-7000 <br /> 1 Address 1720 South Fresno Ave . , Stockton , CA 95206 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Charter Way Holdings Phone # <br /> c Contractor Name Walton Engineering , Inc Phone # <br /> 0 <br /> N <br /> T Contractor Address P . O . Box 1025 , West Sacramento , CA 956 1CA Lic # Class A , B Haz <br /> R See Attached <br /> A Insurer Work Comp # <br /> T ICC Technician 's Name Brandon Wahlen Expiration Date 08- 10- 2024 <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 Diesel Fill Sump No Change No Change <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 Date 2 I 12.c .� <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." <br /> Applicant's Signature Title Compliance Manager Date 2/ 1 /2024 <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 Veronica Freitas TITLE Contractor PHONE # 916- 373- 1166 <br /> ADDRESS P . O . Box 1025 , West Sacramento , CA 95691 <br /> SIGNATURE DATE 2/ 1 /2024 <br /> 2 of 6 <br />