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0 9 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3P° FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PE IT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT _ PIPING REPAIR/RETROFIT _ UNDER DISPENSER CONTAINMENT REPAIR/RFTRnFU <br />A <br />SITE #CAL000255085 <br />PROJECT CONTACT & TELEPHONE #916-925-2716 (Linda Steiger or Lee Reeves) <br />C <br />FACILITY NAME 7 -Eleven #32190 <br />IFLIEPA <br />PHONE #209-939-0679 <br />ADDRESS 4943 South State Route 99 - Stockton - California 95206 <br />1 <br />L <br />I <br />CROSS STREET <br />T <br />OWNER/ OPERATOR 7 -Eleven Inc. <br />PHONE #800-828-0711 <br />C <br />Contractor Name Sacramento Equipment Maintenance Company, Inc. (Wo #166863) <br />Phone #916-925-2716 <br />0 <br />N <br />Contractor Address 2533 Connie Drive - Sacramento - CA 95815 <br />U LIC #502377 <br />Class 'A""C61 -040" "Naz" <br />T <br />R <br />Insurer State Compensation Insurance Fund <br />Work <br />A <br />Comp. #1536608 <br />TOther <br />Information <br />O <br />R <br />Phone #916-434-0710 <br />(Linda Steiger) <br />Phone # <br />Tank ID # <br />FN <br />39-1 <br />Tank sire <br />1 000 <br />Chemicals Stored currently / previously <br />Regular <br />Date UST installed <br />39- 2 <br />10,000 <br />-Unleaded <br />MidG2tle-Unleaded <br />06/2003 <br />06 /2003 <br />39_3 <br />10,000 <br />Premium -Unleaded <br />06/2003 <br />P Plan Reviewers Nam Approved Approved with Condition (s) Disapproved <br />L (See attachment win conditions) <br />N <br />A l� wvtl/f A j�4in t G1 t Date ZI 0 <br />r 1 <br />Applicant must perform all work in accordance with San Joaquin County ordinances, state laws and rules and regulations of San Joaquin County, <br />Environmental Health Department. Owner or licensed agent's signature certifies the following: I certify that in the performance of the work for which this <br />permit is issued. I shall not employ any person in such a manner as to become subject to Worker's Compensation laws of California. Contractor's hiring or <br />subcontracting signature certifies the following: I certify that in the performance of the work for which this permit is issued. I shall employ persons subject <br />to Worker's Comoensatiodtaws of-Califmmia. I <br />Applicants <br />Billing Information: <br />Title Linda Steiger - President Date <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below <br />is different that the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />Name: Sacramento Equipment Maintenance Company, Inc. <br />2533 Connie Drive - Sacramento 95815 916-925-2716 <br />Signat <br />Lin a Steiger -President <br />EH230036 <br />(revised 1/31/02) <br />v:\ county \ San joaquin \ env \ forms \ permits \ repairs2 <br />