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99 00 <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 [a PIPING REPAIR/RETROFIT 0 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 /> L Address 4943 S CA 99, Stockton, CA 95215 <br /> TCross Street <br /> Y Owner/Operator 7-Eleven, Inc. Phone# <br /> o Contractor Name Walton En ineerin , Inc. Phone# 916-373-1167 <br /> IN <br /> Contractor Address P.O. Box 1025 CA Lic# 617238 Class <br /> A, B, Haz <br /> A Insurer Attached Work Camp# <br /> C ICC Technician's Name <br /> T arod Burke Expiration Date 06/16/16 <br /> ICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak dele=r,UDC 112,etc.) Installed <br /> T 89 Leak Detector p= R <br /> 3% 01 obimA <br /> N — f <br /> K <br /> JUL 31 201 <br /> E TAL HEAi—a <br /> P E Approved Approved with conditions U Disapprove! NT <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name G3 Cn in nAQ 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 TO <br /> 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 Title Contractor Date 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 F.O. Box 1025,West Sacramento CA 95691 <br /> SIGNATURE IL. A.&- DATE 07/28/2014 <br /> EH230038(revised 10/30/12) <br /> 2 <br />