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• 0 <br /> 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 11 PIPING REPAIR/RETROFIT [I UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name 7-Eleven S# 35355 Phone# <br /> I Address 3202 West Hammer Lane, Stockton, CA 95209 <br /> L <br /> 1 Cross Street Kelley Drive <br /> T <br /> Y Owner/Operator 7-Eleven, Inc. Phone#(714) 771-5484 <br /> o Contractor Name Walton Engineering, Inc. Phone# 916 373-1165 <br /> T Contractor Address P.O. Box 1025 CA Lic#617238 ClassA,B,HazMat <br /> A Insurer see attached certificate Work Comp# <br /> T ICC Technician's Namesee attached certificates Expiration Date <br /> Q <br /> R ICC Installers Name see attached certificates Expiration Date <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 Cold-Start of the Monitoring <br /> A System (Console) <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> A / (See Attachment With Conditions) <br /> N <br /> Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL ORK 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." Jj J <br /> 9 s /�C ���f)S l Title 1 " tt^IL i\e ✓ 'l3�/\�Ct�!D9��, !%� , <br /> Applicant's Si nature <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 +�hl uN Cs ti j�7t I�J Nth) �N� TITLE PHONE# <br /> T O-A <br /> ADDRESS 0- 1 5 � EA,!Q, <br /> SIGNATURE �" S(i�'� DATE �O 2t - 11 <br /> EH230038(revised 02/20/09) <br /> 1 <br />