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E'NVIRONMNTAL 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 />ITANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT HOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone #Dul c inea Webb 916-373-1166 <br />A <br />C <br />Facility Name Quik Stop #120 <br />Phone# 510-657-8500 <br />I <br />L <br />Address 9321 Thornton Road <br />I <br />T <br />Cross Street Wagner Heights Road <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 3900 Commerce Drive <br />CALic# 617238 Class HAZ A, B <br />T <br />R <br />Insurer State Fund <br />Work Comp# 713-4927-2008 <br />A <br />T <br />T <br />ICC Technician's Certification Number <br />Expiration Date <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Date UST Installed <br />Currently/Previously <br />#1 <br />12 K <br />Gasoline - 87 <br />T <br />A <br />#2 <br />12 K <br />Gasoline - 91 <br />N <br />K <br />P <br />❑Approved ---'N;pproved with conditions ❑Disapproved <br />L <br />See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name—Date U <br />APPLICANT MUST PERFORM ALL 16ORK IN ACCORDANCE WITH SAN JQZ1Myi"TVCMDIWnagaXrE 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 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 />Applicants Signature Title Date <br />BILLING INFUKMA I IUN: <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 Webb TITLE Compliance ManagerPHONE # 916-373-1166 <br />P.O. Box 1025, West Sacramento, CA 95691 <br />SIGNA <br />EH230038 (revised 12/31/07) <br />1 <br />