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�m <br /> COUNTY - X111p <br /> SAN JOAQUIN Enviro jm�e a hit- C <br /> 2022 <br /> II APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIFIIR�M� 'tjALTISER\j CE LTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> 91 TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Veronica Freitas 916-373- 1166 <br /> A <br /> C Facility Name 7-Eleven #41187 Phone # <br /> Address <br /> L 1829 N . Wilson Way , Stockton , CA 95205 <br /> TCross Street Bradford St <br /> Y Owner/Operator Vixxo / 7- Eleven Phone # <br /> C Contractor Name Phone # <br /> 0 Walton En ineerin , Inc. 916-373- 1166 <br /> N Contractor Address P . O . Box 1025 , West Sacramento , CA 95691 CA Lic # 617238 Class AB Haz <br /> T <br /> R Insurer S <br /> A ee Attached Work Comp # See Attached8 <br /> C ICC Technician 's Name Expiration Date <br /> T Robert Bush p � 4/11 /2023 <br /> RICC Installer' s Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> lie, 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T L3 - 87 lank annular sensor 87 - Gasoline no change <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A VQV� <br /> N Plan Reviewers Name 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." /J <br /> Applicant's Signature L/1 Title Compliance Manaqer Date 11 /3/2022 <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 , West Sacramento , CA 95691 <br /> SIGNATURE � ,%� l • DATE 11 /4/2022 <br /> 2 of 6 <br />