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SA i v ' 0 A (� U N Environmental Health Department <br /> _�. C. 0 U N T Y ---. <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: CONTACT PHONE # <br /> Lacy Dodge 916-669- 1849 <br /> FACILITY NAME : FACILITY PHONE# <br /> 7- Eleven #41531 <br /> FACILITY ADDRESS : CROSS STREET: <br /> 3379 N Tracy Blvd . Tracy , CA Clover <br /> OWNERIOPERATORi PHONE: <br /> 7- Eleven , Inc 916-74270232 <br /> CONTRACTOR NAME : PONE : <br /> Wilkey' s Construction INC . 530 - 741 -2233 <br /> CONTRACTOR ADDRESS : CA LICENSE # <br /> 4557 Sky Way Dr . Olivehurst , CA 95961 722945 Class A HAZ B <br /> HAZARDOUS WASTE CERTIFICATE : WORKERS COMP # <br /> X YES No 914069821 <br /> FIRE DISTRICT: PERMIT # <br /> South San Joaquin Fire Authority COM21 -0183 <br /> I Ann 1T»rvn aicE Cticm1%0n1� :3TOREb PROi' vaeu IrvS TALL DATE <br /> r633 <br /> zuK KUL 10/2021-592-04 on NUL i0/202 i <br /> -592-04 12K DSL 10/2021 <br /> D APPROVED PPROVED WITH CONDITIONS ❑ 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 AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING' 1 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 RNIA." <br /> Applicants Signature <br /> Title Date <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 - Crystal Justice Date 04/08/2021 <br /> Mailing address P Box 07 1 Dallas TX 75221 <br /> Signaiure' Daytime Phone 916-742-0232 <br /> 3of8 <br />