Laserfiche WebLink
UI Environmental Health Department <br /> OUNTY <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 # <br /> A <br /> C Facility Name 7-Eleven 32190 Phone # 209-939-0679 <br /> 1 Address 4943 S Hwy 99, Stockton, CA 95215 _ <br /> I Cross Street Munford Ave <br /> T -- --- _ . <br /> Y Owner/Operator 7-Eleven Phone # 209-939-0679 <br /> o Contractor Name Able Maintenance Inc / Christina Tran Phone # 707-569-4791 <br /> N T 9� Parkway,Contractor Address 3224 Re , Santa Rosa, CA 95403 CA Lic# 312844 Class B A C10 HAZ <br /> AInsurer Praetorian Insurance Company Work Comp # 204000064 <br /> T ICC Technician's Name See Attached Expiration Date <br /> R ICC Installer's Name See Attached Expiration Date <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 87 product piping <br /> A 91 product piping <br /> N — — - <br /> K Diesel product piping <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se5 Attachment With Conditions) <br /> A <br /> 7 <br /> N Plan Reviewers Name <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORD ANCES, 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 /> I -� <br /> Applicant's Signature ! ,: '' Title Protect and Permit Coordinator Date 2' � `^'5 <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 Christina Train TITLE Project and Permit Coordinator PHONE# 408-213-6039 <br /> ADDRESS 680 Quinn Ave , San Jose, Ca 95112 <br /> r <br /> SIGNATURE DATE �2- <br /> 2 of 6 <br />