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} <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQ,UIN COUNTY <br /> 600 Last Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Lar: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 GAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT [?[COLD STARTIEVR UPGRADE <br /> F EPA Site# Pro;ect Contact&Telephonel#uul cinea Webb 916-373-1166 <br /> C Facility Name 7-Eleven #2368-14117 Phone# 209-463`1259 <br /> 1 <br /> L Address 1999 N. Main Street <br /> I Cross Street <br /> T 209-830-9917 <br /> Y Owner/Operator 7-Eleven Phone <br /> C Contractor Name Walton Engineering, Inc. Phone# 916-372-1888 <br /> 0 <br /> N Contractor Address 3900 Commerce Drive CALic# 617238 Class Ar B <br /> T <br /> RInsurer State Fund Work Comp# BB1093003 <br /> A -- <br /> c ICC Technician's Name Expiration Date <br /> T - <br /> © !CC Installer s Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> a.87 pipe q sump,91 leak detector.UDC 112.e1c.) Installed <br /> T 91 Turbine Sump 10 K Gasoline - 91 <br /> I A <br /> N <br /> K <br /> P - Approved Approved with conditions Disapproved <br /> L (See Attachment nth Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT FAUST 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.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECCME SUBJECT <br /> TO 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 Title Date <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 Dulcinea Webb-Covan TITLECompliance Manager PHONE# 916-373-1166 <br /> ADDRESS P .O. Box 1025, West Sacramento, CA 95691 <br /> SIGNATUR�a ' t, `�... .. f�., ��.; . -- - ._ DATE <br /> EH230038(revised 02120109) <br /> 1 <br />