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(Ug 3a3j <br /> 1,►(0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> 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 XUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Angel Rodriguez 916-373-1165 <br /> A <br /> C Facility Name 7-Eleven#17334 Phone# 209-951-6745 <br /> 1 Address 4501 North Pershing Ave. Stockton CA 95207 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator 7-Eleven,Inc. Phone# 480-682-4215 <br /> C Contractor Name Walton Engineering,Inc. <br /> o Phone# 916-373-1165 <br /> N <br /> T Contractor Address P.O. Box 1025 West Sacramento CA 95691 CA Lic#617238 Class AB HAZ <br /> R <br /> A Insurer State Compensation Insurance Fund Work Comp# 9113339-2016 <br /> C (ration Date 1-15-2018 ICC Technician's Name David Delgado-5246959 Ex <br /> T g P <br /> R ICC Installer's Name David Delgado-5246959 Expiration Date 9-24-2018 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T 91 vapor Spill Bucket <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." C NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF E WORK FOR WHICFVrHIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title C a�T2 A-- -0 r Date (O -2 <br /> r <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 M 1C� &Lll WA1 To✓\ TITLE Pre . PHONE# <br /> ADDRESS P.O. Box 102.5 West Sacramento CA 95691 <br /> SIGNATURE _ DATE — VZ <br /> EH230038(revised 7-26-2016) 2 <br />