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02/07/2014 10:41 91637311 WALTONENGINEERING PAGE 03/09 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 100 DAYS FROM THE APPROVAL DATE. INDICATE PERMITTYPE BELOW: <br />D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Veronica Freitas 916.373.1167 <br />O <br />Faolllty.Name Tower Mart 4#104 <br />Phone # 209-858-4998 <br />I <br />Address 192 Lathrop Road, Lathrop, CA 95330 <br />I <br />r <br />Cross Street Came brid Dr. <br />Y <br />Owner/Operator Tower Energy Group <br />Phone # <br />o <br />Contractor Name Walton Engineering, Inc. <br />Phone # 916-373-1167 <br />T <br />Contractor Address P.O. Box 1025, West Sacramento, CA 95691 <br />CA Lic #617238 Class A,B,IIaz <br />A <br />Insurer QBE Insurance Corp <br />Work Comp u QWC4000674 <br />GICC <br />T <br />Technicians Name <br />'Robert Bush <br />Expiration Date <br />OR <br />R <br />ICC Installer's Name <br />Expiration Data <br />Tank system work area <br />(La. 6rplpllla eump,el lEaR00100lm, UDC 12, ole.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />Diesel STP Sensor <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Rsviewers Name Date 0 a` V(l <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 ISSUE), 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 CAUFORNIA.' <br />' c <br />A licnnr.-Sl nalura Title Const. Coord. Dnro 01./27/2014 <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. II <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 Veronica Freitas TITLE Const. CGGrd. PHONE# 916-373-1167 <br />ADDRESS P.O. Rnx 11125.West Sacr2lnento CA 95691 <br />SIGNATUREL__ 14° DATE 01/2.7/1,014 <br />EH230038 (reW2atl 10/30/12) <br />Received Time Feb, 7, 2014 9:50AM No.5150 <br />