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SANJOAQUIN 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 PERMIT TYPE BELOW: <br /> ❑ 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 /> � Facility Name 7-Eleven #43208 Phone # <br /> I L Address2705 Country Club Blvd. , Stockton, CA 95204 <br /> T Cross Street N. Ryde Ave. <br /> Y Owner/Operator 7-Eleven Phone # <br /> C Contractor Name Walton Engineering, Inc Phone # <br /> 0 <br /> N T Contractor Address P.O. Box 1025, West Sacramento, CA 956 1CA Lic # 617238 Class A, B Haz <br /> A Insurer See Attached Work Comp # <br /> TICC Technician's Name Expiration Date <br /> RICC 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 Replaced Diesel Leak Detector on 2/14/25 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions El Disapproved <br /> L ( XeA achment With Conditions) <br /> N Plan Reviewers Name Date Y�W-11 15 <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 � N-�-� Title Compliance Manager Date 06/05/2025 <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 06/05/2025 <br /> 2of6 <br />