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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 ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT [3 COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephonel#ulcinea Webb 916-373-L166 <br /> A Phane# 209-463-1259 <br /> c Facility Name 7-Eleven E 1 evens #2 3 6 8-141'17 <br /> L <br /> Address 1999 N. Main Street <br /> I Cross Street <br /> T <br /> Y Owner/Operator <br /> 7-Eleven Phone# 209-830-9917 <br /> C Contractor Name Walton Engineering, Inc. Phone# 916-372-1888 <br /> T <br /> Contractor Address 3900 Commerce Drive CALic# 617238 ClassHA� A, B <br /> R Insurer State Fund Work Comp# BB1093003 <br /> A <br /> T IGC Technician's Name Expiration Dale <br /> T <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (le,87 pooh sump.91 Irak deledor,UDC 1R,etc) Installed <br /> T 91 Turbine Sump 10 K Gasoline - 91 <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 <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 Tdke Dale <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 Webb-Cavan TITLEComplianee ManagerpHONE# 916-373-1366 <br /> ADDRESS P.O. BOX 1025, West Sacramento, CA 95691 <br /> SIGNATUR � <br /> EH230D38(revised 02120109) <br /> 1 <br />