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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY riLGIUVED <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 MAR 0 9 2016 <br />APPLICATION FOR UNDERGROUND STORAGE TANK ENVIRONMENTAL <br />RETROFIT OR PIPING REPAIR PERMIT t-7Al W -`tP°AR1"kf7-:,NT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT [R PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Veronica Freitas - 916-373-1166 <br />A <br />C <br />Facility Name 7 -Eleven #32262 <br />Phone # 209-830-9917 <br />1 <br />L <br />Address 2360 W Grantline Road Tragy, CA 95376 <br />TCross <br />Street Joe Pombo Pk <br />Y <br />Owner/Operator 7 -Eleven, Inc. <br />Phone # <br />o <br />Contractor Name Walton Engineering, Inc. <br />Phone # "16-373-1166 <br />T <br />Contractor Address P.O. Box 1025 West Sacramento CA 95691 <br />CA Lic #617238 Class A B Haz <br />R <br />A <br />Insurer <br />Work Comp # <br />Q <br />T <br />ICC Technician's Name <br />Expiration Date <br />Q <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />UDC 1/2, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, etc.) <br />T <br />89 Fill SLAII Container <br />A <br />N <br />K <br />P <br />❑ Approved ® Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name po�- Date 6 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN OUNTY 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." A. <br />lApplican Si nature Title Const. Coordinator Date 03/04/2016 <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 Vernllirn Freitas TITLEConct onrrlinatnr PHONE # 916--173-1167 <br />ADDRESS P 0 Rnx 1 f1?5 WPct Sacramento, CA 95+621 <br />SIGNATURE 1L. A -le- DATE 03/04/2016 <br />EH230038 (revised 10/30/12) <br />2 <br />