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SAN JOAQUIN Environmental Health Department <br /> COUNTY <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 /> O TANK RETROFIT 0 PIPING REPAIRIRETROFIT a(UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# KEVIN BROWN 1' (559)444-1730 <br /> C Facility Name 7-ELEVEN INC. Phone# 800-255-0711 <br /> 1 Address 4501 N. PERSHINE AVE., STOCKTON CA.95207 <br /> L <br /> T Cross Street ROSEMARIE LN. <br /> Y Owner/Operator 7-ELEVEN INC. Phone# 800-255.0711 <br /> Q Contractor Name LC SERVICES Phone# (559)4441730 <br /> 0 <br /> T Contractor Address 3887 N.VALENTINE AVE.,FRESNO,CA,93722 CA Lic# 779267 Class A, B,C,HAZ <br /> R Insurer ACE AMERICAN INSURANCE COMPANY <br /> A Work Comp# C8520907A <br /> T ICC Technician's Name MARK STEINHAUER Expiration Date 0 /01/2019 <br /> 0ICC Installer's Name TIM HARDIN Expiration Date <br /> R P 04/18/2019 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (,.a.87PO gwmp.91k ENetlor,UDC12,dc.) Installed <br /> T REMOVE 8 REPLACE CUSTOMER DAMAGED - NA <br /> A DISPENSER <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A 7 � <br /> N Plan Reviewers Name ,• L W Date 1 � <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 WHHIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." CC- <br /> ��� — - AGENT 12/26/18 <br /> licant'a Signeturo - Itle Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME KEVIN BROWN TITLE AGENT PHONE# (559)4441730 <br /> ADDRESS 3887 N.VALENTINE AVE,FRESNO,CA.93722 <br /> SIGNATUREDATE 12126/16 <br /> 7 — <br /> 2of6 <br />