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RECEIVED <br /> SAN10 A Q U I N Environmental Health Departme <br /> C O U N T Y - AUG 2 4 2023 <br /> APPLICATION FOR UNDERGROUND STORAGE TQIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT PERMIT/ SERVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> STANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # CAL000265293 Project Contact & Telephone # Dale Adams 530-2104111 <br /> C Facility Name 7A 1 Site # 32190 Phone # (209) 939=0679 <br /> � Address 4943 S Hwy 99 , Stockton , CA 95215 <br /> Cross Street Arch Rd . <br /> T <br /> Y Owner/Operator 7-Eleven , Inc. Phone # 479402- 1031 <br /> o Contractor Name Wilkey' s Construction , Inc. Phone # 530.741 .2233 <br /> T Contractor Address 4557 Skyway Dr. Olivehurst , CA 95961 CA Lic # 722945 Class A HAZ B <br /> A Insurer State Compensation Ins Fund Work Comp # 914069822 <br /> C <br /> T ICC Technician 's Name Dale Adams Expiration Date 5-24-25 <br /> Q <br /> R ICC Installer's Name Dale Adams Expiration Date 4-5-25 <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 Mid rade Tank 10 , 000 gal Midgrade Fuel 7/21 /03 <br /> A Premium Tank 10 , 000 gal Premium Fuel 7/21 /03 <br /> N <br /> K <br /> P ❑ Approved 6eA <br /> proved with conditions ❑ Disapproved <br /> L hment With Conditions) <br /> A _ <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA TH 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 WORFOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." / <br /> ljox� Title Supervisor Date !/ ' 6 /z, <br /> Signatur <br /> ,Applicants' / - � !� <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 Dale Adams TITLE Supervisor PHONE # 530-741 =2233 <br /> ADDRESS 5 SaaDr.JOVehU <br /> SIGNATLIRE � � `� <br /> 2of6 <br />