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1 1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK 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 REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Dulc inea C- 916-373-1166 <br /> A Facility Name 7-Eleven #2369-14117 Phone# 249-463-1259 <br /> 1Address 2725 Country Club Lane <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator 7-Eleven Phone# 209-463-1259 <br /> cContractor Name Walton Engineering, Inc Phone# 916-373-1166 <br /> 0 <br /> N Contractor Address P•O• Box 1025 CA Lic# 617238 Class A,B Ha <br /> T <br /> R Insurer State Fund Work Camp# EB1093003 <br /> A <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T TLS Monitor System <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See ch nt With Conditions) <br /> N Plan Reviewers Name Date_ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA 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 <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 CALIFORNI " <br /> Applicant's Slgnat <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 parry 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 Covan TITLI£ompliance Manager PHONE# 916-373-1166 <br /> ADDRESS F .O. Box 1025 , West Sacramento, CA 95691 <br /> SIGNATURE <br /> DATE <br /> EH230038(revised 02120109) <br /> 1 <br />