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sr ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />CE <br />1868 E. Hazelton Ave., Stockton, California 95205 r' <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANKE,,��I�1E;AL <br />RETROFIT OR PIPING REPAIR PERMITr-RT;NT <br />- <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />XTANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Angel Rodriguez 916-373-1165 <br />A <br />C <br />Facility Name 7 -Eleven #20632 <br />Phone # 209-952-3543 <br />I <br />L <br />Address 4627 DaVinci Ave Stockton CA 95207 <br />1 <br />Cross Street <br />T <br />Y <br />Owner/Operator 7 -Eleven, Inc. <br />Phone # 480-682-4215 <br />C <br />Contractor Name Walton Engineering, Inc. <br />Phone # 916-373-1165 <br />o <br />N <br />Contractor Address P.O. Box 1025 West Sacramento CA 95691 <br />CA Lic # 617238 Class AB HAZ <br />T <br />AInsurer <br />State Compensation Insurance Fund <br />Work Comp # 9113339-2017 <br />T <br />ICC Technician's Name David Delgado - 5246959 <br />Expiration Date 9-24-2018 <br />R <br />ICC Installer's Name David Delgado - 5246959 <br />Expiration Date 9-24-2018 <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />91 & 87 Direct Bury Spill Buckets <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A°0g'ra <br />N <br />��^^ <br />Plan Reviewers Name Qetka Naa�j,, 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 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 WS OF CALIFOR IA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANC F THE WORK FO HICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />/ <br />Applicant's Signature ' Title Date Z l7 <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 />y l <br />NAME %'l L(("\C%C ` wCA 1 �-6y, TITLE Pre <br />PHONE # <br />onnoGee P.O. Box 1025 West Sacramento CA 95691 <br />SIG <br />EH230038 (revised 7-26-2016) 2 <br />