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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY i��f, �E <br /> 1868 E. Hazelton Ave., Stockton, California 95205 1 g I <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 JUL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONNIE.NTAL <br /> RETROFIT OR PIPING REPAIR PERMIT HFWJ. -I U�Eap•RWrNT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> X TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Angel Rodriguez 916-373-1165 <br /> A <br /> C FacilityName 7-Eleven#17647 Phone# 209-239-2329 <br /> 1 Address <br /> L 1048 West Yosemite Manteca 95336 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator 7-Eleven,Inc. Phone# 480-682-4215 <br /> C Contractor Name Walton Engineering,Inc. Phone# 916-373-1165 <br /> O <br /> N Contractor Address P.O. Box 1025 West Sacramento CA 95691 CA Lic#617238 Class AB HAZ <br /> T <br /> R <br /> A Insurer State Compensation Insurance Fund Work Comp# 9113339-2016 <br /> T ICC Technician's Name David Delgado- 5246959 Expiration Date 12-29-2019 <br /> R ICC Installer's Name David Delgado-5246959 Expiration Date 9-24-2018 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T 87&91 Direct Bury Fill Buckets <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A �n �/� ` <br /> N Plan Reviewers Name �1 C 1 1 1a l ),) 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 LAWSF CALIFORNIA." CONT ACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OFT WORK FOR WHICH Ti <br /> S PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." p <br /> Applicant's Signature Title Date _ p <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 11(I t cm A-pt wP C f--�N TITLE �(Z(�/j - PHONE# <br /> ADDRESS P.O. Box 025 West Sacramento CA 95691 <br /> SIGNATURE DATE 3. — Ir 3 <br /> EH230038(revised 7-26-2016) 2 <br />