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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 9 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name BONFARE MARKET 435 Phone# (4 0 8) 93 3-4422 <br /> I <br /> L Address 15 West Grantline Road <br /> I Cross Street Holly Street <br /> T <br /> Y Owner/Operator Sean Kapoor Phone# <br /> C Contractor Name Walton Engineering, Inc. Phone#(916) 373-1152 <br /> O <br /> N Contractor Address PO Box 1025 CA Lic#617 2 3 8 Class A B Ha zMa <br /> T <br /> A Insurer State Comp Fund Work Comp# 00071349272008 <br /> T ICC Technician's Name see attached certifications Expiration Date <br /> R ICC Installer's Name see attached certifications Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T Cold Start as a result o <br /> A Phase II EVR/ISD Upgrade <br /> N <br /> K <br /> P ❑ Approved with conditions El Disapproved <br /> L (SeXApproved <br /> lachment With Conditions) <br /> A <br /> N 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 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 COMPENSATI LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANC K FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ZaNFX eLc Iw�Q�JY itl�g9 <br /> Applicant's Signature Title .` 01 �i Date v/ <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 appjpant, e.g. property owner, the party must acknowledge this <br /> responsibility for the bi((��Ing.byy si�1 at u and date below. / IITS'_ c <br /> Gt/,nR.�4 €€T a. oo 4 Z7e� $�c (408) 933-4422 <br /> NAME P TITLE PHONE# <br /> ADDRESS 461 S . Milpitas Blvd. , Suite 1, Milpitas, CA 95035 / �Q <br /> SIGNATUREAWL DATE 1 !/� <br /> EH230038(revised 02/20/09) <br /> 1 <br />