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0 • <br /> ENVIRONMENTAL HEALTH DEPAR I <br /> E <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 NOV 2 0 2014 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> ENVIRONMENTAL HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK DEPARTMENT <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT R PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Veronica Freitas - 916-373-1166 <br /> A <br /> C Facility Name Quik Sto #148 Phone# <br /> � <br /> Address 205 W. Lockeford Street Lodi CA 95240 <br /> I Cross Street Church Street <br /> T <br /> Y Owner/Operator Quik Stop Markets,Inc. Phone# <br /> C Contractor Name Walton Engineering,Inc. Phone# 916-373-1167 <br /> 0 <br /> T Contractor Address P.O. Box 1025 CA Lic# 617238 Class A,B,Haz <br /> R <br /> A Insurer Attached Work Comp# <br /> TICC Technician's Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T 87 91 Seconda Line <br /> A <br /> N 87 Piping m <br /> K <br /> P ❑ ApprovedA proved with conditions 11 Disapproved <br /> L ( e tt hment With Conditions) <br /> A <br /> N Plan Reviewers Name �- -( Date 11/18/2014 <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." <br /> Applicants Signature Title Contractor Date 11/18/2014 <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 TITLE Contractor PHONE# 916-373-1167 <br /> ADDRESS P.O. Box 1025,West Sacramento, CA 95691 <br /> SIGNATURE A-w- DATE 11/18/2014 <br /> EH230038(revised 10/30/12) <br /> 2 <br />