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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 D PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT MCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> APhone# 209-951-6745 <br /> C Facility Name 7-Eleven #17334 <br /> I <br /> L Address 4501 N. Pershing Ave. , Stockton, CA 95207 <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator 7-Eleven Inc . Phone# <br /> D Contractor Name Walton Engineering, Inc . Phone# 916-373-1167 <br /> 0 <br /> N Contractor Addressp.O. Box 1025 , W.Sacramento CALic# 617238 ClassA B Haz <br /> T <br /> R <br /> Insurer BE Insurance C r Work Comp# <br /> DICC Technician's Name Expiration Date <br /> T <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leek detach,,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P Approved Approved with conditions Disapproved <br /> L ons) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALLWO 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: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 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 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 /> NAMEWalton Engineering, Inc . TI TLE r'jLt rgC t,nr PHONE# 91 r.-171-11 r.7 <br /> ADDRESS P.Q.— Pnx 109S . k;eqt- Sain-ra-mento. CA 95691 <br /> SIGNATUREC—Foo� DATE 07Z22/13 <br /> EH230038(revised 10/30/12) <br /> 2 <br />