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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E WEBER AVE,3PO 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 /> 1 <br /> L <br /> I CROSS STREET <br /> T OWNER/OPERATOR 7-Eleven Inc. PHONE#800-828-0711 <br /> v <br /> C Contractor Name Sacramento Equipment Maintenance Company,Inc. (Wo#121718) Phone#916-925-2716 <br /> 0 <br /> N Contractor Address 2533 Connie Drive-Sacramento-CA 95815 CA LIC#502377 Class"A""C61-D40""Haz" <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 (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 39392 10,000 MirlGrade-Unleaded 06/2003 <br /> N 39-3 10,000 Premium-Unleaded 06/2003 <br /> K <br /> P Approved Approved with Condition(s) Disapproved <br /> L (See attachment with conditions) <br /> A n j <br /> N Plan Reviewers Name IN Date z o <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 agents signature certifies the following: I certify that in the performance of the work for which this <br /> permit is issued. I shall n employ any person in such a manner as to become subject to Worker's Compensation laws of California. Contractor's hiring or <br /> subcontracting signature ce fies the following-. I certify that in the performance of the work for which this permit is issued. I shall employ persons subject <br /> A Worker's Compens�F sof IifQrnia. <br /> Applicants Signature: rvL� Title Linda SteiOer-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 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 /> 2533 nie Drive-Sacramento,- 95815 916-925-2716 <br /> Signa U(o <br /> EH230036 Linda keiger-President <br /> (revised 1/31/02) <br /> v:\county\san joaquin\env\forms\permits\repairs2 <br />