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SAN JOAQUIN Environmental Health Department <br /> - COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> 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 ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Sarah Jablonsky- Const. Mngr, 916-373- 1165 <br /> A <br /> C Facility Name Quik Stop # 132 Phone # <br /> 1 Address 3555 W. Hammer Ln . , Stockton , CA 95219 <br /> L <br /> Cross Street Mariners Dr. <br /> T <br /> Y Owner/Operator Quik Stop Markets , Inc. Phone # <br /> C Contractor Name Walton Engineering , Inc. Phone # <br /> 0 9 9 , <br /> N <br /> T Contractor Address PO Box 1025 , West Sacramento , CA 95691 CA Lic # 617238 <br /> Class A , B , HAZ <br /> AInsurer State Compensation Insurance Fund Work Comp # 9113339 <br /> T ICC Technician 's Name Rafael Flores Cert# 8712762 Expiration Date 01 /26/23 <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 1 /2 , etc.) Installed <br /> T Tank # 1 10K Gasoline 87 <br /> A Tank #2 10K Gasoline 89 <br /> N <br /> K Tank #3 8K Gasoline 91 <br /> P ❑ Approved Ypproved with conditions ❑ Disapproved <br /> L (qpe7AYachment 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 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 SignatureW �RTitle Construction Manager Date ' 2 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant , e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Sarah Jablonsky TITLE Construction Manager PHONE # 916-373- 1165 <br /> ADDRESS PO Box 1025 , West Sacramento , CA 95691 <br /> SIGNATURE <br /> --�,' Y / d" ` � "^�` DATE <br /> 2 of 6 <br />