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S� o0 7 BZ�Y <br /> ENVIRONMENTAL HEALTH DEPARTEIVED <br /> SAN JOAQUIN COUNTY <br /> 1868 E. Hazelton Ave., Stockton, California 95205 OCT 0 6 2017 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> ENVIRONMENTAL HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK DEPARTMENT <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT X UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# <br /> A Project Contact&Telephone# Angel Rodriguez 916-373-1165 <br /> FacilityName 7-Eleven#17334 Phone# 209-951-6745 <br /> I <br /> L Address 4501 North Pershing Ave. Stockton CA 95207 <br /> T Cross Street <br /> y Owner/Operator 7-Eleven,Inc. Phone# 480-682-4215 <br /> 0 <br /> 0 Contractor Name Walton Engineering,Inc. Phone# 916-373-1165 <br /> N <br /> r Contractor Address P.O.Box 1025 West Sacramento CA 95691 CA Lic#617238 Class AB HAZ <br /> RInsurer State Compensation Insurance Fund <br /> A P Work Comp# 9113339-2016 <br /> oICC Technician's Name David Delgado-5246959 <br /> T g Expiration Date 1-15-2018 <br /> p ICC Installer's Name David Delgado-5246959 Expiration Date 9-24-2018 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i e.87 piping sump.91 leak di t tor,UDC 1/2,etc.) y Installed <br /> T 91 Spill Bucket <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions) ^ <br /> N Plan Reviewers Name_ G 1et"a ( Data I0 ' Io -�V 4 <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 /> AT IN THE PERFORMANCE OF HE WORK FOR W CH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.• <br /> Appiimnrs Signature Title Date OAA <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 sig/nature and date below. T� <br /> NAME AIC"A VI/ A-L TITLE tom/ "tD`IRF'-1 PHONE# 9(6 3 4-3 -((5 2_ <br /> ADDRESS P.O. Bo 1025 West acramento CA 95691 <br /> SIGNATURE — DATE S� (�- <br /> EH230038(revised 7-26-2016) 2 <br />