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�1 <br /> RECEIVEDRE APR O 3 20" <br /> SA 10 A H I Al Environmental Health Department <br /> C_ 0t ] \j ll-- y IV APR y 201 ` .. <br /> �w�NVIRONMEN-FAL HEALTH <br /> NVIRONMC -AL HEAL 41 , <br /> DEPARTMENT <br /> APPLICATION FOR UNDER �.. GE TANK INSTALLATION PERMIT <br /> T14C APPLICATION FOR INSTALLATION 017 UNDERGROUND STORAGE TANKS IS ONLY VALID I OR THE- CALENDAR YEAR IN WITICH II HAS BFLN <br /> ISSUED, A PERMIT MAY BE EXTENDED IN10 THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO run RrOUESTmG THIS EXTENSION TDIRTY <br /> DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONF YEAR CKIENSION MAYBE GRANILD nY I: HD UPON Rl CFIPT OF THIS <br /> LETTER <br /> PROJECT CONTACT: CONTACT PHONE # <br /> Karly Zacher 916-669- 1849 <br /> FACILITY NAME: FACILITY PHONE# <br /> 7-Eleven, Inc. 916-742-0232 <br /> FACILITY ADDRESS: CROSS STREET: <br /> 1515 East Main Street N. Wilson Way <br /> OWNERIOPERATOR: PHONE: <br /> 7-Eleven, Inc. 916-742-0232 <br /> CONTRACTOR NAME: PHONE: <br /> Walton Engineering, Inc. 916-372- 1888 <br /> CONTRACTOR ADDRESS: CA LICENSE # <br /> P.O. Box 1025, West Sacramento, CA 95691 617238 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP # <br /> A3846 X YES NO 9113339 <br /> FIRE DISTRICT: PERMIT # <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> O APPROVED O APPROVED WITH CONDITIONS O DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE <br /> FOLLOWING' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED., I SHALL NOT EMPLOY <br /> ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" <br /> CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING 01 CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.' <br /> Applicant's Signature - � �(i,. _ <br /> Tillo Karly Zacher ,,, I � I � =E ot- Date of e% �p <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8-hour minimum installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name Karly Zacher oN Date a4•PVan __ <br /> Mailing Address 11280 Tradelft Center Drive, Rancho Cordova, 95742 <br /> Signaturo -I. ..,,1> cLd_.— �+ ��- Daytime Phone Ins-� 3 . O�t O}y <br /> 3of8 <br />