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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,30 FLOOR <br /> STOCKTON,CA 95202 <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT,OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS,INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT PIPING REPAIR/RETROFIT UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br /> F EPA SITE#CAL000255085 PROJECT CONTACT&TELEPHONE #916-925-2716(Linda Steiger or Lee Reeves) <br /> A <br /> C FACILITY NAME 7-Eleven#32190PHONE#209-939-0679 <br /> L ADDRESS 4943 South State Route 99-Stockton-California 95206 <br /> I <br /> L <br /> I CROSS STREET <br /> T OWNER/OPERATOR 7-Eleven Inc. PHONE#800-828-0711 <br /> Y <br /> C Contractor Name Sacramento Equipment Maintenance Company,Inc. (Wo#123843) Phone#916-925-2716 <br /> O <br /> N Contractor Address 2533 Connie Drive-Sacramento-CA 95815 CA LIC#502377 Class"A""C61-1340""Ham" <br /> T <br /> R Insurer State Compensation Insurance Fund Work Comp.#1536608 <br /> A <br /> C Other Information <br /> T <br /> 0 Phone#916-434-0710 <br /> R <br /> (Linda Steiger) <br /> Phone# <br /> Tank ID# <br /> Tank size Chemicals Stored currently/previously Date UST installed <br /> T 3939=1 15,000 Regular-Unleaded 06/2003 <br /> A 392 10,000 MidGrade-Unleaded 0612003 <br /> N 39-3 10,000 Premium-Unleaded 0612003 <br /> K <br /> P Approved Approved with Condition(s) Disapproved <br /> L (See a chment with conditions) <br /> A DI-l°t <br /> N Plan Reviewers Name Date <br /> Applicant must perform ark in accordance with San Joaquin County ordinances,state laws and rules and regulations of San Joaquin County, <br /> Environmental Health D art ent. Owner or licensed agent's signature certifies the following:I certify that in the performance of the work for which this <br /> permit is issued. I s all of a ploy any rson in such a manner as to become subject to Worker's Compensation laws of California. Contractor's hiring or <br /> subcontracting si nat 'fies 2 fo wi g:I certify th In the performance of the work for which this permit is issued. I shall employ persons subject <br /> to Worker's C pen "o laws of Califor <br /> Applicants Sig ure: Title Linda Steiger-President 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 the party designated below <br /> is different*25nie <br /> mit applicant,e.g.property owner,the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name: o Equipment Maintenance Company,Inc. <br /> Drive cr ente-CA 95815 916-925-2716 <br /> Sigr <br /> a Skeiger-president <br /> EH230038 <br /> (revised 1/31/02) <br /> v:\county\san joaquin\env\forms\permits\repairs2 <br />