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I a 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK 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 <br />EPA Site # <br />Project Contact & Telephone ADul c inea Covan916 - 3 7 3 -116 6 <br />� <br />Facility Name Quik Stop #124 <br />Phone# 510-657-8500 <br />I <br />L <br />Address 505 N. Main Street <br />TCross <br />Street <br />Y <br />Owner/Operator Quik Stop Markets <br />Phone # 510-657-8500 <br />C <br />Contractor Name Walton Engineering, Inc. <br />Phone# 916-372-1888 <br />O <br />N <br />Contractor Address P.O. Box 1025 <br />CA Lic # 617238 Class HAZ A, B <br />T <br />R <br />A <br />Insurer State Fund <br />Work Comp # BB1093 003 <br />C <br />r <br />ICC Technician's Name <br />Expiration Date <br />o <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />#1 <br />10 K <br />Gasoline - 87 <br />T <br />A <br />#2 <br />10 K <br />Gasoline - 89 <br />N <br />K <br />#3 <br />8 K <br />Gasoline - 91 <br />P <br />❑ Approved fes, Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />6c <br />Plan Reviewers Name Datej <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 <br />TO 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 Signa e ` "-'— Title Date ` -Aig "00 <br />BILLING INFOFZMA I ION: <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 Dul c inea Covan TITLECompl i ance Manager PHONE # 916-373-1166 <br />ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />1 <br />,TE 6-00'(4> <br />