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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY 1868 E. Hazelton Ave., Stockton, California 95205 Telephone: (209) 468-3420 Fax: (209) 468-3433 APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT � COLD START/EVR UPGRADE 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 A VhQ. (' 20ct V *% G, Q. L TITLE JP�/1 PHONE # 916-372-1888 ADDRESS P..00'. Box 1025 West Sacramento CA 9.5691 C SIGNATURE_ (� � 1 _ DATE j D^ S — EH230038 (revised 7-26-2016) EPA Site # CA1,000412498 Project Contact & Telephone # Angel Rodriguez 916-373-1165 A � FLF Facility Name Colonial Ener ;x40134 Phone # 7147615426 I Address 1434 W Yosemite Ave. Manteca CA 95337 TCross Street Y Owner/Operator Alaeddin Hassan Phone # 7144485000 o Contractor Name Walton Engineerin Inc. Phone # 916-373-1165 T Contractor Address P.O. Box 1025 West Sacramento CA 9569 CA Lic # 617238 Gass AB HAZ A Insurer State Compensation Insurance Work Comp # 9113339-2017 T ICC Technician's Name David Delgado - 5246959 Expiration Date 1-01-2019 oICC R Installer's Name David Delgado - 5246959 Expiration Date p 1-01-2019 Tank system work area Tank Size Chemicals Stored Currently Date UST (: a 87 piping sump. 91 leak detector. IJDC 112, etc.) Installed T Diesel Spill Bucket Replacement A N P Approved Approved with conditions n Disapproved L (Se A achment With Conditions)=NVIRONMENTAL HEAL A N f}� ( n DEPARTMENT '�(;� "l attQ Flak �� Plan Reviewers Name � Date 10 �J — APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN 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 (THE WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." (/j� C� P� — �— Applicant's Signatu a Title 1 Date v 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 A VhQ. (' 20ct V *% G, Q. L TITLE JP�/1 PHONE # 916-372-1888 ADDRESS P..00'. Box 1025 West Sacramento CA 9.5691 C SIGNATURE_ (� � 1 _ DATE j D^ S — EH230038 (revised 7-26-2016)