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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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> D TANK RETROFIT NPIPING REPAIRIRETROFIT D UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name 7-Eleven #17334 Phone# 209-463-1259 <br /> � Address 4501 N. Pershing Ave. , Stockton, CA 95207 <br /> 1 Cross Street Rosemarie Lane <br /> T <br /> Y Owner/Operator 7-Eleven Phone# <br /> Contractor Name Walton En ineerin Inc. Phone# 916-373-1167 <br /> 0 9 gr <br /> " Contractor Address P.O. <br /> T Box 1025, W. Sacramento CALic# 617238 Class Ag Haz <br /> A Insurer Praetorian WOrkCOmp#QWC4000674 <br /> O ICC Technician's Name See attached Expiration Date <br /> T <br /> R ICC Installer's Name See attached Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Lc 87 Aping sump,91 leak Cetetlor.UDC 12,etc.) Installed <br /> T Discriminating 91 Sensor 10, 000 Gasoline <br /> A <br /> N <br /> K <br /> P ❑ Approved proved with conditions L1 Disapproved <br /> L Be ehment With Conditions) <br /> A <br /> " Plan Reviewers Name Date / L. <br /> APPLICANT MUST PERFORM ALL WORKACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HALTH 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." 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 Tie. 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 Walton Engineering, Inc. TITLE Contractor PHONE# 916-373-1167 <br /> ADDRESS P.O. BOX 1025, West Sacramento, CA 95691-1025 <br /> SIGNATURE DATE 07-05-12 <br /> EH230038(revised 08/1/11) <br /> 2 <br />