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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E WEBER AVE, 3RD FLOOR <br />STOCKTON, CA 95202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br />THIS PERMIT 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/RETROFIT <br />F <br />A <br />EPA SITE #CAD981465438 <br />PROJECT CONTACT & TELEPHONE #916-925-2716 (Linda Steiger or Lee Reeves) <br />C <br />FACILITY NAME 7 -Eleven #19976 <br />PHONE #209-239-3252 <br />I <br />L <br />ADDRESS 1399 North Main Street - Manteca - California 95336 <br />I <br />L <br />I <br />CROSS STREET <br />T <br />OWNER/ OPERATOR 7 -Eleven Inc. <br />PHONE #800-828-0711 <br />Y <br />C <br />Contractor Name Sacramento Equipment Maintenance Company, Inc. (Wo #124679) <br />Phone #916-925-2716 <br />0 <br />N <br />Contractor Address 2533 Connie Drive - Sacramento - CA 95815 <br />CA LIC #502377 <br />Class "A" "C61 -1340" "Haz" <br />T <br />R <br />Insurer State Compensation Insurance Fund <br />Work Comp. #71310369-06 <br />A <br />C <br />T <br />Other Information <br />0 <br />R <br />Phone #916-434-0710 <br />(Linda Steiger) <br />Phone # <br />Tank ID # <br />Tank size <br />Chemicals Stored currently / previously <br />Date UST installed <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />39- <br />P Approved Approved with Condition (s) Disapproved <br />L (See attachment ith conditions) (� <br />A <br />N Plan Reviewers Name G Date l 0 <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 <br />this permit is issued. I s l �of employ any person in such a manner as to become subject to Worker's Compensation laws of California. Contractor's <br />hiring or subcontracti g gna'kure certifie a following: I certify that in the performance of the work for which this permit is issued. I shall employ <br />persons subjects ompe sati la of California. <br />Applicants Signature: Title Linda Steiger - President Date �� C <br />Billing Information: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated <br />below is different that the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date <br />below. <br />Name: Sacra ento Equipment Maintenance Company, Inc. <br />.2 C n'ie Drive - Sacramento - CA 95815 916-925-2716 <br />Signature y k` <br />Linda St Iger - President <br />EH230038 <br />(revised 1/31/02) <br />v:\ county \ san joaquin \ env \ forms \ permits \ repairs2 <br />