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NMENTAL HEALTH DEPARTMENT <br /> E � p <br /> SAN JOAQUIN COUNTY <br /> JUL 16 2018 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> ENVIRONMENTAL HEAL i PLICATION FOR UNDERGROUND STORAGE TANK <br /> DEPARTMENT RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT 0 PIPING REPAIR/RETROFIT RUDGREPAtR}RETROFfF° 0 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Angel Rodriguez 916-373-1165 <br /> A <br /> C FacilityName 7-Eleven#17334 Phone# 209-951-6745 <br /> 1 Address 4501 North Pershing Ave.Stockton CA 95207 <br /> L <br /> TCross Street <br /> Y Owner/Operator 7-Eleven,Inc. Phone# 480-682-4215 <br /> C Contractor Name Walton Engineering,Inc. Phone# 916-373-1165 <br /> 0 <br /> N Contractor Address P.O.Box 1025 West Sacramento CA 95691 CA Lic#617238 Class AB HAZ <br /> T <br /> AInsurer State Compensation Insurance Fund Work Comp#9113339-2016 <br /> 0 ICC Technician's Name David Delgado-5246959 <br /> T g Expiration Date 1-15-2018 <br /> 0ICC Installer's Name David Delgado-5246959 <br /> R g Expiration Date 9-24-2018 <br /> Tank system work area Tank Size Chemicals Stored Currently Date <br /> lnst US <br /> (I.e.87 piping sump.91 leak detector,UDC 12,etc.) <br /> T 91 va or Spill Bucket <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L ee parent With Conditions) <br /> IN <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN AC OR C H SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH ENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHI IS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LA OF CALIFORNIA." C NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMANCE OF E WORK FOR WHIC HIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> Applicant's SignatureTine C ti��R D- T-0 h D.I. —2 g <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 M IC-k� W <br /> 1 AI Td✓\ TITLE Pre PHONE# <br /> ADDRESS P.O. Box 102f5 West Sacramento CA 95691 <br /> SIGNATURE DATE <br /> EH230038(revised 7-26-2016) 2 <br />