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• <br /> 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 a PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Dul c ine a C . 916-373 -1166 <br /> A7-Eleven #2369-14117 Phone# 209-463-1259 <br /> C Facility Name <br /> 1 Address 2725 Country Club Lane <br /> L <br /> TCross Street <br /> Y Owner/Operator 7-Eleven EEEE <br /> E# 209-463-1259 <br /> c ContractorName Walton Engineering, Inc <br /> O 7238 Class A,B Haz <br /> N Contractor Address P . O. Box 1025 CA Lic# <br /> T <br /> R Insurer State Fund Work Comp# BB1093003 <br /> A <br /> T ICC Technician's Name Expiration Date <br /> °a ICC Installer's Name Expiration Date <br /> Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently installed <br /> (i.e,87 piping sump,91 leak detector.U©C 112,etc.) <br /> 87 STP sump sensor 10 K 87 - Gasoline <br /> T <br /> A 91 STP sump sensor 10 K 91 - Gasoline <br /> N <br /> K <br /> rA Approved Approved with conditions F1 Disapproved <br /> (S e ttachment With Conditions) <br /> 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 <br /> IN THE PERFORMANCE OFLTHESWORK FOR WHICH THIS PERMIT OF CALIFORNIA" RIS ISSUED,RING OI SHALL EMPLOY PERSONS SUBJECT TOR SUBCONTRACTING SIGNATURE IWORKER'S FIES THE OCOMPENSATION CERTIFYLLOWING: "I <br /> THATAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature <br /> 7itie 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 Covan TITLE�ampllanCe Manager PHONE# 916-373-1166 <br /> ADDRESS P . O . Box 1025 , West Sacramento, CA 95691 <br /> .�_..___ DATE 9.3 <br /> SIGNATURE lt�� <br /> EH230038(revised 02120109) <br /> 1 <br />