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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,3RD FLOOR STOCKTON,CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE.DO NOT WRITE IN ANY SHADED AREAS.INDICATE PERMIT TYPE BELOW: _TANK RETROFIT-/\-PIPING REPAIR/RETROFIT_UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT ----------------------------------------------------------------------- ---------------------------------------- ------------------------------------------------------------------------- I I_______r________________ �- -- I F, ; EPA SITE # PROJECT CONTACT & TELEPHONE # 1 I 11 Mike Karvelot IA 1 C FACILITY NAME Quikstop Site # 00152 PHONE # 510 445 2288 I ------ ---- ------------------------------------------------------------�--------------------------------------------------------------3 I L I ADDRESS 1721-1 S0. Cherokee, Lodi, CA 95240 I_ __ I1 CROSS STREET E. Kettleman Lane T 1 ' --------------------------------------------------------------------- ---------------------------------------------------------------------------- -------------------------------------------------------------- Y TOWNER/OPERATOR Quikstop Markets, Inc ` PHOE # 510 657 8500 1 - - `---------------------------------------------------------------' CONTRACTOR NAME Triangle Environmental, Inc PHONE # 818 840 7020 C O •------------------------- -- ------------------- CONTRACTOR ADDRESS 2525 W. Burbank Blvd, Burbank CA 91505 1 CA LIC # 673971 1 CLASS A N T - -------und -L ----------------------------------------------------------------------------- ----------------------------- ------------------------------------ I INSURER State F WORK.COMP.# 1555802-04 R f I ----------------------------------------------------------------------------------------------------------------------------------------------------f--------------------------------------------------------------i A OTHER INFORMATION C j I ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ T 1 PHONE # 818 840 7020 1 0 I R I PHONE # �______________ _ -_____ I TANK ID # I TANK SIZE ; CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 1 39- 1 1 ' , 39- i - + i T ! ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 39- 1A I I 1 4-------------------- K 39 -------------------------------------------------------------------- --------------------------------------------j N 39 1 , � K 139- 1 , ' 1 39- 1 - ---------------------------------i t - I-------------------------------------------- 39i 1 1 , P L I APPROVED APPROVED WITH CONDITIONS) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) I N i PLAN REVIEWERS NAME DATE -- -------------------------------- ---------------------------� APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF 1 SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER I AS TO BECOME SUBJECT TO WORKER'S COMPENSAT LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT I E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S PENSATI S OF CALIFORNIA." I APPLICANT'S SIGNATURE: TITLE DATE _8/25/2004 I-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_____7 BILLING INFORMATION: Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name: Triangle Environmen Inc Address: 2525 W. Burbank Blvd. Phone #: 818 840 7020 Signature