Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT Rq PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Dul c inea C . 916-373-1166 <br /> A <br /> G Facility Name 7-Eleven #2369-14117 Phone# 209-463-1.259 <br /> 1Address 2725 Country Club Lane <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator 7-Eleven Phone# 209-463-1259 <br /> C Contractor Name Walton Engineering, Inc Phone# 916-373-1166 <br /> 0 <br /> N Contractor Address P .O . Box 1025 CA Lic# 617238 Class A, B Ha z <br /> T <br /> R <br /> A Insurer State Fund Work Comp# EB1093003 <br /> T <br /> T ICC 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 172,etc-) Installed <br /> T 87 STP sump sensor 10 K 87 - Gasoline <br /> A 91 STP sump sensor 10 K 91 - Gasoline <br /> N <br /> K <br /> P ❑ Approved Cchment <br /> pproved with conditions ❑ Disapproved <br /> L (See 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 <br /> TO 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 Date <br /> BILLING INFORMATION-. <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Dulcinea C©van TITLE�QmPliance Manager PHONE# 916-373-1166 <br /> ADDRESS P .O . Sox 1025 , West Sacramento, CA 95691 <br /> SIGNATURE - DATE ' a 3 <br /> EH230038(revised 02120109) <br /> 1 <br />