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ENVIRONMENTAL HEALTH DEPARTMENT <br /> V <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax- (209) 468-3433 fiJAY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> �!4EN i <br /> RETROFIT OR PIPING REPAIR PERMIT k7` <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> XTANK RETROFIT 0 PIPING REPAIRIRETROFIT OUDC REPAIR/RETROFIT oCOLD STARTIEVRUPGRADE <br /> F EPA Site# Project Contact&Telephone# Angel Rodriguez 916-373-1165 <br /> A <br /> C Facility Name 7-Eleven#20632 Phone# 209-952-3543 <br /> 1 Address 4627 DaVinci Ave Stockton CA 95207 <br /> L <br /> T I Cross Street <br /> Y Owner/Operator 7-Eleven,Inc. Phone# 480-682-4215 <br /> C <br /> 0 Contractor Name Walton Engineering,Inc. 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#9113339-2017 <br /> C <br /> T ICC Technician's Name David Delgado-5246959 Expiration Date 9-24-2018 <br /> 0 <br /> R ICC Installer's Name David Delgado-5246959 <br /> Expiration Date 9-24-2018 <br /> Tank system work area Tank Size Chemicals Stored Currently t <br /> Date LIST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) <br /> T 91 &87 Direct Bu!y Spill Buckets - Installed <br /> led; <br /> A <br /> N <br /> K <br /> P L] Approved Approved with conditions L] Disapproved <br /> L (SeAttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Sol)A Date <br /> . 5-a <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." 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 /> c7 <br /> Applicant's Signature Title Date C(— <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EIHD 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 —TITLE —PHONE# <br /> ADDRESS P-0. Box 1025 West Sacramento CA 95691 <br /> SIGNATURE DATE <br /> EH230038(revised 7-26-2016) 2 <br />