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= ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY G�CC�COdC � <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 OCT 0 6 2017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT PERMITISERVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> O TANK RETROFIT 0 PIPING REPAIR/RETROFIT XUDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Angel Rodriguez 916-373-1165 <br /> AFacil Name 7-Eleven#17334 <br /> C #Y Phone# 209-951-6745 <br /> I <br /> L Address 4501 North Pershing Ave.Stockton CA 95207 <br /> TCross Street <br /> Y Owner/Operator 7-Eleven,Inc. Phone If 480-682-4215 <br /> D <br /> 0 Contractor Name Walton Engineering,Inc. Phone# 916-373-1165 <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 I Work Comp#9113339-2016 <br /> C ICC Technician's Name David Delgado-5246959 <br /> T g Expiration Date 1-15-2018 <br /> O ICC 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 UST <br /> (Le,87 piping sump,91 leak tletector.UDC 12.etc.) Installed <br /> T 91 Spill Bucket <br /> A <br /> N <br /> K <br /> P ❑ Approved ,,�1 Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A /� <br /> N Plan Reviewers NameDate y • o <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 /> E PERFORMANCE OFTHE 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 /> Applicants Signature Title Date S— / <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 AICbt� VV 4-L � TITLE PHONE# ?(6 3 )-3 —((5—Z <br /> ADDRESS P.O. Bo4c 1025 West Pacramento CA 95691 <br /> SIGNATURE DATE <br /> EH230038(revised 7-26-2016) 2 <br />