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• <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />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 R COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Veronica Freitas 916-373-1167 <br />A <br />C <br />Facility Name uik Sto #120 <br />Phone # 209-478-7149 <br />1Address <br />L <br />9321 Thornton Road Stockton, CA 95209 <br />1 <br />T <br />Cross Street Wagner Hei hts Road <br />Y <br />Owner/Operator Quik Stop Markets, Inc. <br />Phone # <br />o <br />Contractor Name Walton Engineering, Inc. <br />Phone # 916-373-1167 <br />T <br />Contractor Address p O. Box 1025 West Sacramento CA 95691 <br />CA Lic # 617238 ClassA B Haz <br />A <br />Insurer attached <br />Work Comp # <br />T <br />ICC Technician's Name attached <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work areaDate <br />Tank Size <br />Chemicals Stored Currently <br />UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />MSC Cold Start <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(Se� Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name b <br />- 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 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." [//Lys, <br />Applicant's Signature Title Construction Coordinator Date 04/12/14 <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 Veronica Freitas <br />TITLE Construction Coordinator PHONE# <br />916-373-1167 <br />ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br />SIGNATURE DATE 04/12/14 <br />EH230038 (revised 10/30/12) <br />