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I, <br /> J I 1 (}AA(� N{�) Environmental Health Department <br /> J O <br /> COU I�ITY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN <br /> ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO END REQUESTING THIS EXTENSION THIRTY <br /> DAYS PRIOR TO THE END OF THE CALENDAR YEAR, A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS <br /> LEITER. <br /> =n HZOTr_ nhfTAnT• CONTACT PHONE # ''.. <br /> Karly Zacher 916-669- 1849 <br /> ' FACILITY NAflf :^ FACILITY PHONE# V <br /> 7-Eleven , Inc. 916-742-0232 (° '}, Siv, I (' <br /> FACILITY ADDRESS : - Lia CROSS STREET: <br /> 9200-Haekberry-Rd, lrving TX 75083 <br /> OWNER/OPERATOR: PHONE: <br /> 7-Eleven , Inc. 91 &742-0232111_ <br /> CONTRACTOR NAME: PHONE: <br /> TBD <br /> CONTRACTOR ADDRESS : CA LICENSE # <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP # <br /> L I�I�IIi et <br /> YES NO <br /> FIRE DISTRICT: PERMIT # <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> D APPROVED D APPROVED WITH CONDITIONS n DISAPPROVED <br /> N f (see attachments) <br /> PLAN REVIEWER'S NAME kra DATEL2 r <br /> `� '. <br /> APPLICANT MUST PERFORM ALL WORK ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S 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 "I 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 CALLIIFORNIA." <br /> Applicant's Signature <br /> Title Flt t c _ Date , <br /> Indicate the responsible party to be !lied 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 it ` Z,e4€ p Dateyyt C� 17-� <br /> Mailing Address P�tko <-f ( r C ny 2 f <br /> Signature Daytime Phone <br /> 3 of <br />