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M <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 />D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone If Veronica Freitas - 916-373-1166 <br />A <br />Facility Name 7 -Eleven #2369-17647 <br />Phone # 209-239-2329 <br />c <br />I <br />L <br />Address 1048 West Yosemite Avenue Manteca CA 95337 <br />1 <br />Cross Street El Portal Avenue <br />T <br />Y <br />Owner/Operator evennc.Phone <br /># <br />C <br />Contractor Name Walton Engineering, Inc. <br />Phone # 916-373-1167 <br />0 <br />N <br />Contractor Address P.O. Box 1025 <br />CA Lic # 617238 Class A, B, Haz <br />T <br />R <br />Insurer Attached <br />Work Comp # <br />A <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />I ICC Installers Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping wmp, 91 leak detector, UDC la, etc.) <br />Installed <br />MSC Cold Start <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(S Attachment With Conditions) <br />A <br />N <br />�'.. <br />Plan Reviewers Name 1 � lllllJ� W 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 AGENTS 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 rifle Contractor 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 <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# 916-373-1166 <br />ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br />Imn_siwn iov " O� nATP <br />EH230038 (revised 1O/3o/12) <br />