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1] <br />E <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT k 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 Countryside 76 <br />Phone # <br />� <br />Address 14971 N. Highway 88, Lodi, CA 95240 <br />TCross <br />Street <br />Y <br />Owner/Operator Ru in r P d a <br />Phone # 209-727-3064 <br />C <br />Contractor Name Walton Engineering, Inc. <br />Phone # 916-373-1167 <br />N <br />T <br />Contractor Address P.O. Box 1025 <br />CA Lie # Class <br />617238 A, B, Haz <br />A <br />Insurer QBE Insurnace Corp. <br />Work Comp # QWC4000674 <br />TICC <br />Technician's Name <br />Expiration Date <br />RICC <br />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 />MSC Cold Start <br />T <br />A <br />N <br />K <br />P <br />❑ Approved <br />Approved with conditions ❑ Disapproved <br />L <br />A <br />(Se hment With Conditions) <br />N <br />Plan Reviewers Name <br />Date 10q 13 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. <br />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 />Applicant's Signature <br />Title Construction Coordina or Date 101091201-3 <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 Walton Engineering, Inc. TITLE Contractor PHONE # 916-373-1167 <br />ADD <br />SIGNA <br />EH230038 (revised 10/30/12) <br />2 <br />