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SAN 10AQUIN <br />-COUNTY <br />Environmental Health Department <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 <br />EPA Site # <br />Project Contact & Telephone # <br />Sarah Jablonsky-Const. Mngr, 916-373-1165 <br />A <br />C <br />Facility Name 7 -Eleven 441341 <br />Phone # <br />I <br />L <br />Address 4405 Pacific Ave., Stockton, <br />CA 95207 <br />Cross Street Bianchi Rd. <br />T <br />Y <br />Owner/Operator 7 -Eleven, Inc. <br />Phone # 916-742-0232 <br />C <br />Contractor Name Walton Engineering, <br />Inc. <br />Phone # 916-373-1165 <br />O <br />N <br />Contractor Address PO Box 1025, West Sacramento, CA 95691 <br />CA Lic # <br />617238 Class A, B, HAZ <br />T <br />R <br />Insurer State Fund <br />Work Comp # 9113339 <br />A <br />TICC <br />Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals <br />Stored Currently <br />Date UST <br />(Le, 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />12,000 gal <br />87 Gasoline <br />9/22/1999 <br />T <br />A <br />8,000 gal <br />91 Gasoline <br />9/22/1999 <br />N <br />K <br />P <br />❑ Approved <br />Approved with conditions <br />❑ Disapproved <br />L <br />A <br />See Attachment With Conditions) <br />N <br />Plan Reviewers Name i <br />Date <br />(Moto <br />APPLICANT <br />MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />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." <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature <br />Title Construction Manager <br />Date �► 1 �i <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must <br />acknowledU e this responsibility for the billing by signature and date below. <br />kmkj ll:: MMUTFUM11111: M10 <br />PO Box 1025, West Sacramento, CA 95691 <br />SIGNATU <br />TE �tiuh 1 Z�- <br />