Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPAT <br /> SAN JOAQUIN COUNTY N96flVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 OCT 2 5 2018 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TAWRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT [R PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Veronica Freitas - 916-373-1166 <br /> C Facility Name 7-Eleven #32190 Phone# 209-939-0679 <br /> i <br /> Address <br /> L 4943 S CA 99, Stockton, CA 95215 <br /> I Cross Street <br /> T <br /> Y Owner/Operator 7-Eleven, Inc. Phone# <br /> C Contractor Name Walton Engineering, Inc. Phone# 916-373-1166 <br /> O <br /> N Contractor Address P.O. Box 1025 CA Lic# 617238 <br /> T Class A, B, Haz <br /> R <br /> A Insurer Attached Work Comp# <br /> T ICC Technician's Name Expiration Date 06/19/2020 <br /> T Ismael Rios p� <br /> Q <br /> R ICC Installer's Name 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 89 Drop Tube <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se A Iachment With Conditions) <br /> N Plan Reviewers Name Qe4m a Date (� 'El (J"�'I <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." L <br /> Applicant's Signature Title Contractor Date 10/23/18 <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 `°" ` - DATE 10/23/18 <br /> EH230038(revised 10/30/12) <br /> 2 <br />