Laserfiche WebLink
u <br />ENVIRONMENTAL <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />.� due].4XI 1. <br />. <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT IR COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Veronica Freitas - 916-373-1167 <br />C <br />I <br />Facility Name 7 -Eleven #35355 <br />Phone,4 209-951-3345 <br />L <br />Address 3202 West Hammer Lane Stockton CA 95209 <br />T <br />Cross Street <br />Kelley Drive <br />Y <br />Owner/Operator 7 -Eleven Inc. <br />Phone # <br />C <br />N <br />Contractor Name Walton Engineering, Inc. <br />Phone # 916-373-1167 <br />R <br />Contractor Address P.O. Box 1025 CA Lic # 617238 Class A, B, Haz <br />A <br />C <br />Insurer Attached <br />Work Comp # <br />T <br />ICC Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 97 leak detector, UDC tit, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />MSC Cold Start <br />A <br />N <br />K <br />P <br />L <br />Cl Approved ❑ Approved with conditions ❑ Disapproved <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name <br />— Date <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 AGENT'S SIGNATURE CERTIFIES <br />THE PERFORMANCE <br />THE FOLLOWING: "I CERTIFY THAT IN <br />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 <br />THAT IN THE <br />CERTIFIES THE FOLLOWING: "I CERTIFY <br />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____ <br />-- uc iiuce�Zyi --Date—JW--11--U <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 <br />DATE_ 07-11-14 _ <br />EH230038 (revised 10/30/12) <br />2 <br />