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05/0412009 13:17 91637311 WALTONENGINEERING PAGE 10 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 4683420 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 ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site #Project <br />Contact & Telephone # <br />A <br />C <br />Facility Name 7 -Eleven #2368-32262 <br />Phone # 209830-9917 <br />I <br />Address 2360 W. Grain ine Roo <br />L <br />TCross <br />Street <br />Y <br />Owner/Operator 7 -Eleven <br />Phone # 209-830-9917 <br />OContractor <br />Name a on ngineering, Inc.916-372-188T- <br />Phone # " 6 - <br />O <br />0 <br />NContractor <br />T <br />Address Commerce rive <br />CA Lic0 ClassHAZ A, 1B <br />A <br />Insurer State Fund <br />Work Comp # 713 - 4 9 2 7- 2 0 0 8 <br />C <br />ICC Technician's Name <br />Expiration xpiration Date <br />R <br />ICG Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(I.e. 87 piping —p..91 leak detealor, UDC 1/2, eta) <br />Installed <br />T <br />Gasoline 87 <br />20 K <br />A <br />N <br />Gasoline 89 <br />10 K <br />K <br />Gasoline 91 <br />10 K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(Se Attachment With Conditions) <br />N <br />It <br />Plan Reviewers Name DateA <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "1 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." <br />ApplcanYs Signature Title Dste _ <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 Dul c inea Webb TITLE Compliance Manager PHONE # 916-3-73-1166 <br />P.O. Box 1025, West Sacramento, CA 95691 <br />EH230038 (revised 02/24/09) <br />7, <br />TE S -k4-01 <br />