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SANJOAQUIN Environmental Health Department <br /> COUNTY <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 EHD 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 /> LETTER. <br /> PROJECT CONTACT: Christopher Kolbe CONTACT PHONE#707-921-1308 <br /> FACILITY NAME: 7-Eleven#38616 FACILITY PHONE# <br /> FACILITY ADDRESS: CROSS STREET: Interstate 5 <br /> 601 Carolyn Weston Blvd,Stockton,CA 95206 <br /> OWNER/OPERATOR: PHONE: <br /> 7-Eleven Inc (972)828-7930 <br /> CONTRACTOR NAME: PHONE: <br /> Walton Engineering 916-373-1154 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 3900 Commerce Dr.W. Sacramento, CA 95691 617238.A,B,HAZ <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> X YES NO <br /> FIRE DISTRICT: PERMIT# <br /> Stockton Fire Dept BP20-06452 <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> TANK#1 20,000 GALLONS Regular(E10) <br /> TANK#2 8,000 GALLONS Premium(E10) <br /> TANK#3 12,000 GALLONS Diesel <br /> ❑APPROVED PPROVED WITH CONDITIONS ❑DISAPPROVED <br /> I(see attachments) <br /> PLAN REVIEWER'S NAME DATE�P,t_�� <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 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 CALIFORNIA." <br /> Applicant's Signature <br /> Title Job Captain Date 8/27/2020 <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 Stephen Boyd Date 10/20/2020 <br /> Mailing Address PO Box 711 -Attn: Gasoline Department <br /> Signature -111`j—rya Daytime Phone 972-828-7930 <br /> 3 of 8 <br />