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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PER T TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT )N COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Veronica Freitas 916- 373- 1166 <br /> C Facility Name 7- Eleven #35355 Phone # 209-951 -3345 <br /> 1 Address 3202 West Hammer Lane , Stockton , CA 95209 <br /> L <br /> TCross Street Kelley Dr . <br /> Y Owner/OperatorVlXXO Phone # <br /> C Contractor Name Walton Engineering , Inc Phone # 916- 373- 1166 <br /> O <br /> N <br /> T Contractor Address P . O . Box 1025 , West Sacramento , CA 95691 CA Lic # 617238 Class AB Haz <br /> R <br /> A Insurer See Attached Work Comp # <br /> C <br /> T ICC Technician 's Name Expiration Date <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 87 & 91 Drop Tubes <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L Se Attachment With Conditions) <br /> A ` <br /> N Plan Reviewers Name I Date 11 � � <br /> APPLICANT MUST PERFORM ALL WORK IN , ACCP � H A QUIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY , ENVIRONMENTAL HEALTH D PAR TM {V -OW ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH HIS 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." f ^� <br /> Applicant's Signature Title Contractor Date 1 ( d� <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 Veronica Freitas TITLE Compliance Manager PHONE # 916- 373- 1166 <br /> ADDRESS P . O . Box 1025 , West Sacramento , CA 95691 <br /> SIGNATURE ' DATE <br /> 2of6 <br />