Laserfiche WebLink
tJ I Environmental Health Department <br /> OUN <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 /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact & Telephone # Christina Tran 408-213-6039 <br /> A Facility Name <br /> C Y 7-Eleven Phone # 209-939-0679 <br /> 1 Address <br /> L 4943 S Hwy 99, Stockton, CA 95215 <br /> I Cross Street Munford Ave <br /> T <br /> Y Owner/Operator 7-Eleven; Sean Augustine — Phone# 949-761-2907 <br /> o Contractor Name Service Station Systems, Inc I Phone # 408-971-2445 <br /> T Contractor Address 680 Quinn Ave, San Jose, CA 95112 CA Lic# 485184 Class B C61/D40 HAZ <br /> A Insurer Insurance Company of the West Work Comp # WLV507821801 <br /> TICC Technician's Name see attached Expiration Date see attached <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Date UST <br /> i e.87 in sum 91 leak detector, UDC 12,etc. Tank Size Chemicals Stored Currently <br /> (�• piping P� ) Installed <br /> T , I— <br /> A <br /> N — <br /> K <br /> ------------- <br /> P Approved with conditions ❑ Disapproved <br /> L (Se A achm t lth Conditions) <br /> A <br /> N Plan Reviewers Name <br /> APPLICANT MUST PERFORM ALL WORK IN AbQQdANCE 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: 9 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS 3 <br /> OF CALIFORNIA." <br /> Applicant's Signature `-_ Title Project and Permit Coordinator 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 Service Station Systems: Christina Tran TITLE Prniect and Perm <br /> Itt Goordinator PHONE # 408-213-6039 <br /> ADDRESS 680 Quinn Ave t . r t t- ' ) <br /> SIGNATURE �— j DATE <br /> 3of6 <br />