Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> 1868 E. Hazelton Ave., Stockton, California 95205 AUG 2 1 ZOI$ <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL <br /> RETROFIT OR PIPING REPAIR PERMIT HEALTH DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> X TANK RETROFIT [I PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Angel Rodriguez 916-373-1165 <br /> A <br /> C Facility Name 7-Eleven#32190 Phone# 209-239-0679 <br /> 1 Address <br /> L 4943 South State Route 99 Stockton 95206 <br /> TCross Street <br /> Y Owner/Operator 7-Eleven,Inc. Phone# 480-682-4215 <br /> C Contractor Name dalton Engineering,Inc. Phone# 916-373-1165 <br /> 0 <br /> N Contractor Address P.O. Box 1025 West Sacramento CA 95691 <br /> T CA Lic#617238 Class AB HAZ <br /> AInsurer State Compensation Insurance Fund Work Comp#9113339-2016 <br /> T ]CC Technician's Name David Delgado-5246959 Expiration Date 12-29-2019 <br /> ICC Installer's Name David Delgado-5246959 Expiration Date 9-24-2018 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.97 piping sump,91 leek detector,UDC 112,etc Installed <br /> T Annular Manway Replacement <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 1�1 • Mq 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: 7 CERTIFY <br /> THAT IN THE PERFORMANCE F THE WORK FOR CH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." p <br /> Applicant's Signature Title Date O - <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 /> responsib.ilily for the <br /> p_billing by signature and date below. <br /> NAME /VyC— 4e—k �"l TITLE �rC�S PHONE# <br /> ADDRESS F.O. Box Y025 West Sac amento CA 95691 <br /> SIGNATURE -ffDATE <br /> / , 11 \ E V — <br /> EH230038(revised 7-26-2016) 2 <br />