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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 D PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone #Veronica Freitas 916-373-1166 <br /> C Facility Name 7-Eleven #46641 <br /> Phone # <br /> I <br /> L Address2500 W. Lodi Ave., Lodi, CA 95242 <br /> 1 Cross Street S. Lower Sacramento Ave. <br /> T <br /> Y Owner/Operator 7-Eleven Phone # <br /> C Contractor Name Walton Engineering, Inc Phone #916-373-1166 <br /> 0 <br /> N Contractor Address P.O. Box 1025, West Sacramento, CA 956 1CA Lic # 617238 Class AB Haz <br /> T <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 the 87 and 89 SC's - 7/22/2 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See A tachment With Conditions) <br /> N Plan Reviewers Name s' Date,�iO%2 <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 /> Compliance Manager 07/09/2024 <br /> Applicant's Signature Title Date <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 /> j/ y � <br /> SIGNATURE DATE 07/09/2024 <br /> 2of6 <br />