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• 0 ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton Ave., Stockton, California 95205 Telephone: (209) 468-3420 Fax: (209) 468-3433 APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: O TANK RETROFIT D PIPING REPAIR/RETROFIT O UDC REPAIR/RETROFIT Bi COLD START/EVR UPGRADE BILLING INFORMATION Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per lank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAME Walton Engineering, Inc. TITLE Contractor PHONE# 916-373-1152 PO Box 1025 West Sacramento CA 95691 ,r- EH230038 (revised 07-17.2014) Project Contact & Telephone # Angel Rodriguez /916-37A-1165 F EPA Site If C Facility Name Colonial Energy #40135 Phone # L Address 192 Lathrop Road Lathrop 95330 Cross Street TPhone Y owner/operator Colonial Energy, LLC. # 714-761-5426 o Contractor Name Walton Engineering, Inc. Phone # 916-373-1165 N T Contractor Address PO Box 1025 West Sacramento CA 95691 CA Lie # 617238 Class AB HAZ A Insurer State Compensation Insurance Work Comp # 9113339-15 D T ICC Technician's Name N/A Expiration Date R ICC Installer's Name Expiration Date Tank system work area Tank Size Chemicals Stored currently Date UST Installed (1.e 57 piping wmp. 91 leak d.We ,UDC M. WJ N/A T A N K ❑ Approved [Y Approved with conditions ❑ Disapproved P L (See Attachment With Conditions) A - N Plan Reviewers Name Date APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COU ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN HE 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY AT IN THE PERFORMANCE O TH WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OFCALIFORNIA' Applicants Signature Title ✓OQCF manikce Date �' BILLING INFORMATION Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per lank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. NAME Walton Engineering, Inc. TITLE Contractor PHONE# 916-373-1152 PO Box 1025 West Sacramento CA 95691 ,r- EH230038 (revised 07-17.2014)