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ENVIRONM&TAL HEALTH DE'OARTMENT <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 ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT OLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone #Dul c inea Webb 916-373-1166 <br />A <br />C <br />Facility Name 7 -Eleven #2368-32262 <br />Phone# 209-830-9917 <br />I <br />L <br />Address 2360 West Grantline Road <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator 7- E 1 even <br />Phone # 209-830-9917 <br />C <br />Contractor Name Walton Engineering, Inc. <br />Phone# 916-372-1888 <br />O <br />N <br />Contractor Address 3900 Commerce Drive <br />CA Lic # 617238 Class HAZ A, B <br />T <br />R <br />Insurer State Fund <br />Work Comp# 713-4927-2008 <br />A <br />TICC <br />Technician's Certification Number <br />Expiration Date <br />RI <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Date UST Installed <br />Currently/Previously <br />Gasoline 87 <br />20 K <br />T <br />A <br />Gasoline 89 <br />10 K <br />N <br />K <br />Gasoline 91 <br />10 K <br />P <br />❑Approved Approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />IN <br />Plan Reviewers Nam Date <br />APPLICANT MUST PERFORM ALL WORK INA ORDANCE 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, 1 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 CALIFORNI ll <br />Applicants Sign at e \ Title Date Is <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 Dulcinea Webb TITLE Compliance ManagerPHONE# 916-373-1166 <br />P.O. Box 1025, West Sacramento, CA 95691 <br />SIGNATU <br />EH230038 (revised 12/31/07) <br />1 <br />