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S J�H Jfj Environmental He�lth�ae]� m"t ' <br /> HQ <br /> - <br /> - - COUNTY - - -- <br /> \nv � 7 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT I_ VIRor� MENTa � <br /> t_RMITISERVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> 91 TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Veronica Freitas 916-373- 1166 <br /> APhone # <br /> C Facility Name 7- Eleven # 17334 <br /> I Address <br /> L 4501 N . Pershing Ave . , Stockton , CA 95207 <br /> I Cross Street W. March Ln <br /> T <br /> Y Owner/Operator Vixxo / 7- Eleven Phone # <br /> C Contractor Name Walton Engineering , Inc. Phone # 916-373- 1166 <br /> O <br /> N Contractor Address P . O . Box 1025 , West Sacramento , CA 95691 CA Lic # 617238 Class AB Haz <br /> T <br /> R <br /> A Insurer See Attached Work Comp # See Attached8 <br /> C <br /> T ICC Technician ' s Name Robert Bush Expiration Date 4/11 /2023 <br /> Q ICC Installer's Name p <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (Le, 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T L3 - 87 tank annular sensor no rhqnqp 87 - Gasoline no chancie <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name f 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 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 Title Compliance Manager Date 11 /3/2022 <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 /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Walton Engineering Inc. TITLE Contractor PHONE # 916-373- 1166 <br /> ADDRESS P .O . Box 11025 , West Sacramento , CA 95691 <br /> SIGNATURE �C/� ` DATE 11 /4/2022 <br /> 2of6 <br />