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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 L9 PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C FacilityName 7-Eleven, Inc. S#32190 Phone# <br /> I <br /> L Address 4943 South State Route 99 <br /> 1 Cross Street Arch <br /> T <br /> v Owner/Operator 7-Eleven, Inc. Phone# (916) 463-6720 <br /> o Contractor Name Walton Engineering, Inc. Phone# (916) 373-1165 <br /> T Contractor Address PO Box 1025 CALic# 617238 ClassA B HazMa <br /> A Insurer State Compensation Work Comp# 000713-4927-2008 <br /> DICC Technician's Name See attached certificates <br /> T Expiration Date <br /> O ICC Installer's Name See attached certificates <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector.UDC 12,etc.) y <br /> Installed <br /> T Upgrade 3 tank fill manwa s <br /> A <br /> N <br /> K <br /> P ❑ Approved LTJ Approved with conditions El Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N :Plan Reviewers Name Date <br /> N�(� RIgI pN <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 <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 Tille 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 7-Eleven, Inc. TITLE PHONE# (916) 463-6720 <br /> ADDRESS—2339 Gold Meadow Way, Suite 101 Gold River CA 95670 <br /> SIGNATURE <br /> DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />