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• <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 # <br />C <br />Facility Name Nella - Olympian #427 <br />Phone# 530-885-0401 x2103 <br />I <br />Address 3300 Waterloo Road, Stockton, CA 95205 <br />L <br />TCross <br />Street <br />Y <br />Owner/Operator Nella Oil Company <br />Phone# 530-885-0401 x2103 <br />C <br />Contractor Name Walton Engineering, Inc. <br />Phone# 916-373-1165 <br />O <br />N <br />TCA <br />Contractor Address P.O. Box 102 5 <br />Lic # 617238 Class A B Ha zMa <br />A <br />Insurer SeaBright <br />Work Comp# BB1103003 <br />C <br />T <br />ICC Technician's Name see certifications <br />Expiration Date <br />R <br />ICC Installer's Name see certifications <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 />Tdiesel <br />fill SC & sensor <br />10,000gal <br />A <br />red die UST annular sensor <br />10,000gal <br />N <br />K <br />87 UST annular sensor <br />10,000ga1 <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />See Attacht With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORD(cE SAN JOAQUIN COU ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPA TMENT. 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 PERFORMANC OFT WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." (%) y <br />S� ��� � <br />Applicant's Signature W Title • <br />V 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 />responslbili for the billing by signature and date below. %%�� ,Q�� z <br />NAME 1.t)VY l SUS TITLE ILY, W11fyt � / r1h� Vti"PHONE #%i6 573 � � u-3 <br />ADDRESS��k-4 %i — I L <br />SIGNATURE \J ' � <br />EH230038 (revised 02/20/09) <br />TE )-2-62-16 <br />