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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 REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site Project Contact&Telephone#Dulcinea Webb916-373-1166 <br /> � Facility Name 7-Eleven #2368-32190 Phone# 209-939-0679 <br /> I Address 4943 S . State Hwy 99 <br /> L <br /> TCross Street <br /> Y Owner/Operator 7-Eleven Phone# 209-939-0679 <br /> C Contractor Name Walton Engineering, Inc Phone# 916-373-1166 <br /> 0 <br /> N Contractor Address P.O. Box 1025 gCAgLic# 617238 Class A,B Haz <br /> T <br /> R Insurer State Fund Work Comp# EB1103 003 <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 /> Ii.e.87 piping sump,91 leak det r.UDC 12,etc.) Installed <br /> T <br /> 87 ELLD 15 K 87 - Gasoline <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name W1 6AM+-- Date--l/!D— <br /> APPLICANT <br /> ate l/!D— <br /> NCOUNTY,ENVIRONMENTAL DEPARTMENT.OWNER ORK IN ACCORDANCE WITH SAN LICENSED GENTS SIGNATURE CERTIFIES UIN COUNTY ORDINANCES,STATE LAWS, <br /> AND RULES AND REGULATIONS OF SAN <br /> JOAOU NRTHE FOLLOWING: "II 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 /> TTO HAT COMPENSATION SCONTRACTOR'S OF CALIFORNIA." <br /> IN THE PERFORE <br /> MANCE OFT WORK FOR WH CH TH SSHIRING,ISUBCONTRACTING CERTIFIES <br /> PERMIT IS ISSUED, SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA. <br /> Tine Compliance Manager Data <br /> Applicant's Signatu <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 COyan TITLE ( OmpllanCe ManagerPHONE#916-373-1166 <br /> ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br /> SIGNATUR DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />