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0 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY REGEIVEL <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 NOV 1S 201 <br />APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL <br />RETROFIT OR PIPING REPAIR PERMIT 4:1-aITLJ r1FDAOTBAC►IT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: i <br />D TANK RETROFIT D PIPING REPAIR/RETROFIT O UDC REPAIR/RETROFIT XCOLD START/EVR UPGRADE <br />F <br />EPA Site If <br />Project Contact & Telephone # Angel Rodriguez / 916-37A,-1165 <br />A <br />Facility Name Colonial Energy #40135 <br />Phone # <br />� <br />Address 192 Lathrop Road Lathrop 95330 <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator Colonial Energy, LLC. <br />Phone # 714-761-5426 <br />0 <br />Contractor Name Walton Engineering, Inc. <br />Phone # 916-373-1165 <br />N <br />T <br />Contractor Address PO Box 1025 West Sacramento CA 95691 <br />CA Lic # 617238 Class AB HAZ <br />A <br />Insurer State Compensation Insurance <br />Work Comp # 9113339-15 <br />cICC <br />T <br />Technician's Name N/A <br />Expiration Date <br />OR <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(Le. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />N/A <br />T <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 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 AGENTS 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 Date <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <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 Walton Engineering, Inc. TITLE Contractor <br />PO Box 1025 West Sacramento CA 95691 <br />EH230038 (revised 07-17-2014) <br />2 <br />916-373-1152 <br />I II <br />