Laserfiche WebLink
SANJOAQUIN Environmental Health Department <br /> -- - COU NTY -- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> 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 STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Veronica Freitas 916-373-1166 <br /> A <br /> C Facility Name 7-Eleven #41216 Phone # 209-414-9204 <br /> 1 Address <br /> L . Charter Way , Stockton , CA 95206 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Vixxo Phone # <br /> oContractor Name Walton Engineering , Inc. Phone # 916-373- 1166 <br /> N Contractor Address P . O . Box 1025 , West Sacramento CA Lic # 617238 Class Haz AB <br /> T <br /> R Insurer Work Comp # <br /> A See Attached <br /> c ICC Technician 's Name Expiration Date <br /> T Ismael Rios <br /> Q ICC Installer's Name p <br /> R 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 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se ttachment With Conditions) <br /> A l� <br /> N Plan Reviewers Name Date r 2 742 <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 ate `\ ) ON::> N <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e. g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Walton Engineering Inc. TITLE Contractor PHONE #.916-373-1166 <br /> ADDRESS P . O . Box 1025 , <br /> West Sacramento CA 95691 ii � q <br /> SIGNATURE .C.GTic/'� DATE 1Qj �ujZ> ` <br /> 2 of 6 <br />