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ENVIRON&NTAL HEALTH DO�ARTM <br /> ENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 AEGEIVEL:; <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> JUL 3 0 2015 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK �: NVIROMENA <br /> RETROFIT OR PIPING REPAIR PERMIT , <br /> , r•_,� 0AO- n"r-,,> <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 EPA Site# <br /> A Project Contact&Telephone# Veronica Freitas - 916-373-1166 <br /> C Facility Name 7-Eleven #32262 Phone# <br /> I Address <br /> L 2360 W. Grant Line Rd, Tracy, CA 95377 <br /> T Cross Street Joe Pombo Pkwy <br /> Y Owner/Operator 7-Eleven Inc. Phone# <br /> o Contractor Name Walton Engineering, Inc. Phone# 916-373-1167 <br /> T Contractor Address P.O. Box 1025 CA Lic# 617238 Class A, B, Haz <br /> R <br /> A Insurer Attached Work Comp# <br /> T ICC Technician's Name <br /> arod Burke Expiration Date Attached <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) y Installed <br /> T 91 Relay <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (S a Attachment With Conditions) <br /> A / <br /> N Plan Reviewers Name ( Yl t 'J <br /> CT, Date <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 /> Applicant's Signature Title Contractor Date 7/28/15 <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 Veronica Freitas TITLE Contractor PHONE# 916-373-1167 <br /> ADDRESS P.O. Box 1025 West Sacramento CA 95691 <br /> SIGNATURE 1L.. A-& <br /> DATE 07/28/15 <br /> EH230038(revised 10/30/12) <br /> 2 <br />