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N-- AAR <br /> I T L AL <br /> T <br /> SAN JOAQUIN COUNTY [RECENED <br /> 600 East Main Street, Stockton, California 95202 u v 3 2009 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> VI UNMENT HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPIN(PqRWWWfflAIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#Dul c inea Webb 916-373-1166 <br /> C Facility Name 7-Eleven #20632 Phone# 209-952-3543 <br /> 1 Address 4627 DaVinci Drive <br /> L <br /> TCross Street <br /> Y Owner/Operator 7-E 1 even Phone# 209-830-9917 <br /> C Contractor Name Walton Engineering, Inc. Phone# 916-372-1888 <br /> O <br /> N Contractor Address 3900 Commerce Drive CA Lic# 617238 Class HAZ A, B <br /> T <br /> R <br /> A Insurer State Fund Work Comp# 713-4927-2008 <br /> T <br /> T ICC Technician's Certification Number Expiration Date <br /> RICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T Gasoline 87 10 K <br /> A Gasoline 91 10 K <br /> N <br /> K <br /> P ❑Approved -I�Rpproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Na Date d`� �!� . C ,77 <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 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 WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants SignatuM t Title i\kC Date ' 'a-0cA <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 Dulcinea Webb TITLE Compliance ManagerPHONE# 916-373-1166 <br /> ADDRESS P.O. Box 1025, West Sacramento, CA 95691 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />