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ENVIRONMENTAL HEALTH DEPARREE&EIVED <br /> SAN JOAQUIN COUNTY NOV o 12016 <br /> 1868 E. Hazelton Ave., Stockton, California 95205 <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 /> D TANK RETROFIT ❑PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Veronica Freitas- 916-373-1166 <br /> A <br /> D Facility Name 7-Eleven#17334 Phone# 209-951-6745 <br /> I Address L Add4501 N. Pershing Ave. Stockton CA 95207 <br /> TCross Street Roseffigrie Ln <br /> Y Owner/Operator 7-Eleven Inc. Phone# <br /> C Contractor Name Walton Engineering,Inc. Phone# 916-373-1167 <br /> T Contractor Address P,O.Box 1025 CA Lic# 617238 Class <br /> A,B,Haz <br /> A Insurer Attached Work Comp# <br /> C ICC Technician's Name <br /> T Expiration Date <br /> DICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current( Date UST <br /> (Le.87 plpinp sumo,at leak eeletlw.um iY.etc,) y Installed <br /> T 87 91 STP Sensors <br /> A <br /> N <br /> K <br /> P ❑ Approved L7 Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CdWNTY 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 /> HE 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 /> WORKERS 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 /> Applicants Signature ""`"""' Tore Contractor Date 10/27/16 <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# 916-373-1167 <br /> ADDRESS P.O.Box 1025,West Sacramento,CA 95691 <br /> SIGNATURE /l..A.& DATE 10/27/16 <br /> EH230038(revised 10/30/12) <br /> 2 <br />