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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 # Veronica Freitas 916-373- 1166 <br /> C Facility Name Quik Stop # 124 <br /> Phone # <br /> I <br /> L Address505 N . Main St . , Manteca , CA 95336 <br /> 1 Cross Street E . Alameda St . <br /> T <br /> Y Owner/OperatorQuik Stop Markets , Inc . Phone # <br /> C Contractor Name Walton Engineering , Inc Phone # <br /> 0 <br /> T Contractor Address P . O . Box 1025 , West Sacramento , CA 956 1CA Lic # 617238 Class AB Haz <br /> R Insurer See Attached <br /> A Work Comp # <br /> cICC 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 87-2 & 91 Spill Container Gasoline <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 <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 7/3/2024 <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 <br /> � � DATE 07/03/24 <br /> 2 of 6 <br />