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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : (209 ) 468 -3420 Fax : (209 ) 468 - 3433 <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 /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Angel Rodriguez 916 -373 - 1165 <br /> A <br /> C Facility Name 7-Eleven #32262 Phone #209- 951 -6745 <br /> Address <br /> L 2360 West Grantline Road Tracy CA 95376 <br /> Cross Street <br /> T <br /> Y Owner/Operator 7-Eleven, Inc . Phone # 480- 6824215 <br /> C Contractor Name Walton Engineering, Inc . <br /> Q Phone # 916- 373 - 1165 <br /> N <br /> T Contractor Address P . O . Box 1025 West Sacramento CA 95691 CA Lic # 617238 Class AB HAZ <br /> R <br /> A Insurer State Compensation Insurance Fund Work Comp # 9113339-2016 <br /> T ICC Technician' s Name Expiration Date <br /> T Rafael Flores - 8712762 p 2- 14-2021 <br /> Q ICC Installer' s Name Expiration Date <br /> R Rafael Flores - 8712762 p 244-2021 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc. ) Installed <br /> T Replace 87 Spill Container & Drop Tube in Sum <br /> A <br /> N <br /> K <br /> P ❑ Approved XNApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 41 Date.Q3I II <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 /> Applicant's Signature OL Title PAA n` Date _ <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 <br /> by signature and date below. <br /> NAME 1 D � � d' 2 — TITLE PHONE # <br /> ADDRESS P . O . Box 1025 West Sacramento CA 95691 <br /> SIGNATURE 4DATE ' ' l 9 <br /> EH230038 (revised 7-26-2016) 2 <br />