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SA N sJ O A O I V I I N Environmental Health Department <br /> C0LJNTY— <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 916-343-38,57 <br /> C Facility Name 7-ELEVEN #41531 Phone# <br /> I Address 3379 N TRACY BLVD TRACY, CA 95376 <br /> L <br /> T Cross StreetW CLOVER RD <br /> Y Owner/Operator7-ELEVEN Phone# <br /> C Contractor Name SERVICE STATION SYSTEMS INC Phone# <br /> 0 <br /> N Contractor Address 3900 COMMERCE DRIVE WEST SACRAMENTO,CA 95691 CA Lic# 485184 CIaSS B,C41/D40,HAZ <br /> T <br /> R <br /> A Insurer INSURANCE COMPANY OF THE WEST Work Comp#WLV507821801 <br /> TICC Technician's Name Expiration Date <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 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 Date <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 Title OPERATIONS MANAGER Date 07/29/25 <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 MANAGERPHONE#916-343-3857 <br /> ADDRESS 3900 COMMERCE DRIVE WEST SACRAMENTO, CA 95691 <br /> SIGNATURE LhM4�A� A"4111DATE 07/29/25 <br /> 3 of 6 <br />