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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3" 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 REPAIWRETROFIF <br /> F EPA SITE#CAL000255085 PROTECT CONTACT&TELEPHONE #916-925-2716(Linda Steiger or Lee Reeves) <br /> A <br /> C FACILITY NAME 7-Eleven#32190 PHONE#209-939-0679 <br /> t <br /> L ADDRESS 4943 South State Route 99-Stockton-California 95206 <br /> I <br /> 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#117602) Phone#916-925-2716 <br /> 0 <br /> N Contactor Address 2533 Connie Drive•Sacramento-CA 95815 CA LIC#502377 Class"A""C61-1340""Hai <br /> T <br /> R Insurer State Compensation Insurance Fund Work Comp.#1536608-02 <br /> A <br /> C Other Information <br /> T <br /> 0 Phone#916-434-0710 <br /> R (Linda Steiger) <br /> Phone# <br /> LTATank ID# <br /> Tank size Chemicals Stored currently/previously Dale UA installed <br /> 39_1 15,000 Reoular-Unleaded 06 2003 39-2 10y000 MidGade-U06/2003 <br /> 39-3 10y0WPremium-Unleatletl O6 2003 <br /> P Approved Approved with Condition(s) Disapproved <br /> (See attachment with conditions) <br /> ,��a _ Dare �/— `�—041L �f <br /> N Plan Reviewers Name � <br /> Applicant must perform all work in accordance with San Joaquin County ordinances,state laws and rules and regulations of San Joaquin County, <br /> Environmental Health Department. 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 shall nalLemploy any person in such a manner as to become subject to Worker's Compensation laws of California. Contractor's hiring or <br /> subcontracting signat r certl s the following:I certify that in the performance of the work for which this permit is issued. I shall employ persons subject <br /> to Worker's Complain <br /> Applicants SignalTitle Ltnda Steiner-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 parry designated below <br /> is different that the permit applicant,e.g.property owner,the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name: Sacramento Equipment Maintenance Company,Inc. <br /> 253 nie Drive-Sacramento-CA 95815 916-925-2716 <br /> signatuCA <br /> H2300 <br /> E . <br /> rnda Steiger-President <br /> H2300 <br /> 38 <br /> (revised 1/31/02) <br /> v:\county\san joaquin\env\forms\permits\repairs2 <br />