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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# STEPHANIE CHARISSA 916-343-3857 <br /> A <br /> C Facility Name 7-ELEVEN#43208/59228 Phone# <br /> Address <br /> L 2705 COUNTRY CLUB STOCKTON, CA <br /> Cross Street <br /> T <br /> Y Owner/Operator 7-ELEVEN INC Phone# <br /> o Contractor Name ABLE MAINTENANCE INC Phone# 916-343-3857 <br /> T Contractor Address 3900 COMMERCE DRIVE WEST SACRAMENTO CA Lic# 312844 Class A, B, C10, HAZ <br /> R InsurerCompany Work Comp# 8897913 <br /> q Zurich American Insurance P <br /> T ICC Technician's Name Expiration Date <br /> T SEE ATTACHED P <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 112,etc.) Installed <br /> T NO CHANGES <br /> A <br /> N <br /> K <br /> P Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Zliettil Date u'/1'5/Z S <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 S G"r"W Title OPERATIONS MANAGER Date 10/08/25 <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 STEPHANIE CHARISSA TITLE OPERATIONS MANAGER PHONE# 916-343-3857 <br /> ADDRESS 3900 COMMERCE DRIVE WEST SACRAMENTO, CA 95691 <br /> SIGNATURE s��! / DATE 10/08/25 <br /> 3 of 6 <br />