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SANJOAQUIN Environmental Health Department <br /> --- COU NTY - - <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 # Veronica Freitas 916- 373- 1166 <br /> � Facility Name Quik Stop # 120 <br /> Phone # <br /> I Address 9321 Thornton Road , Stockton , CA 95209 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/OperatorQuik Stop Markets , Inc . Phone # <br /> C Contractor Name Walton Engineering , Inc Phone # 916- 373- 1166 <br /> O <br /> N <br /> T Contractor Address P . O . Box 1025 , West Sacramento , CA 956 1CA Lic # 617238 Class A , B Haz <br /> A Insurer See Attached <br /> Work Comp # <br /> C ICC Technician 's Name See Attached <br /> T 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 91 Drop Tube Gasoline <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L ( See Attachment With Conditions ) <br /> A <br /> N t <br /> Plan Reviewers Name L I dl L D.)bP 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. " <br /> Applicant's Signature Title Contractor Date 05/21 /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 Walton Engineering , Inc TITLE Contractor PHONE # 916-373- 1166 <br /> ADDRESS P . O . Box 1025 , West Sacramento , CA 95691 <br /> SIGNATURE DATE 05/21 /2024 <br /> 2 of 6 <br />