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SA N JOAQUIN 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 qkOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Veronica Freitas 916-373-1166 <br /> � Facility Name 7-Eleven #41342 <br /> Phone# <br /> I Address 1233 E. Dr. MLK Blvd., Stockton, CA 95205 <br /> L <br /> TCross Street E. Charter Way <br /> Y Owner/Operator7-Eleven P.O. Box 711, Dallas, TX 75221 Phone# <br /> C Contractor Name Walton Engineering, Inc Phone#916-373-1166 <br /> 0 <br /> T Contractor Address P.O. Box 1025 CA Lic# 617238 Class A, B Haz <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 Monitor System Cold Start <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ 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." f� <br /> Applicant's Signature '-� Title Compliance Manager Date 06/04/25 <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 Veronica Freitas TITLE Compliance Manager PHONE#916-373-1166 <br /> ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br /> SIGNATURE y DATE 06/04/25 <br /> 2of6 <br />