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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 /> � Facility Name 7-ELEVEN #46641 Phone# <br /> I Address2500 W LODI LODI, CA <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator7-ELEVEN Phone# <br /> C Contractor NameABLE MAINTENANCE INC Phone# <br /> 0 <br /> N T Contractor Address 3900 COMMERCE DRIVE WEST SACRAMENTO,CA 95691 CA Lic# 312844 Class A,B,C10,HAZ <br /> A InsurerZurich American Insurance Company Work comp#8897913 <br /> T ICC Technician's Name SEE ATTACHED 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 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 /`/ <br /> � Date--ILO/2-3/25 <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 6141"(,-SR/ 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�ChAr(�,,Sr DATE 10/08/25 <br /> 3 of 6 <br />