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0 • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT [9 PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Veronica Freitas - 916-373-1167 <br /> A <br /> C Facility Name 7-Eleven#32190 Phone# 209-939-0679 <br /> 1 Address <br /> L 4943 S CA 99, Stockton CA 95215 <br /> I Cross Street <br /> Y Owner/Operator 7-Eleven, Inc. Phone# <br /> o Contractor Name Walton Engineering,Inc. Phone# 916-373-1167 <br /> T Contractor Address P.O. Box 1025 CA Lic# 617238 Class <br /> A, B,Haz <br /> A Insurer Attached Work Comp# <br /> TIGC Technician's Name jarod Burke Expiration Date <br /> R 06/16116 <br /> ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stared Current) Date UST <br /> (i.e.87 piping sump,91 leak detector.UX 112,etc.) y Installed <br /> - <br /> T 89 Leak Detector <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 ORDfNANCES,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 QSSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKERS 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 Title ContractorDale 07/28/2014 <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 Veronica Freitas TITLE Contractor PHONE# 916-373-1167 <br /> ADDRESS P.O.Box 1025,West Sacramento CA 95691 <br /> SIGNATURE ILIu" DATE 07/28/2014 <br /> EH230038(revised 10/30/12) <br /> 2 <br />