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SAN .. ,JOAQUIN Environmental Health Department <br /> -- COU NTY - -- <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 /> Michelle Feasby ( 916 ) 669 1836 <br /> FACILITY NAME : FACILITY PHONE# <br /> 7 - Eleven , #41530 <br /> FACILITY ADDRESS : CROSS STREET: <br /> 1110 N . Main Street Louise <br /> OWNER/OPERATOR : PHONE : <br /> 7 - Eleven , Inc 916-742 - 0232 <br /> CONTRACTOR NAME : PHONE : <br /> Wilkey' s Construction Inc 530 - 741 -2233 <br /> CONTRACTOR ADDRESS : CA LICENSE # <br /> 4557 Sky Way Dr . Oliverhurst , CA 95961 722943) <br /> HAZARDOUS WASTE CERTIFICATE : WORKERS COMP # <br /> A HAZ B YES NO 914069821 <br /> FIRE DISTRICT: PERMIT # <br /> City of Manteca Fire Department 1613 NO : 20 - 3868 <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 633 � b98 -119� 20K UL <br /> 633 - 592 - 04 8K PUL 01 /2112099 <br /> 633 - 592 - 04 12K DSL nlli� v2022 <br /> ❑ APPROVED ❑ APPROVED WITH CONDITIONS ❑ DISAPPROVED <br /> (1(\ see attachments ) <br /> PLAN REVIEWER ' S NAME t IV�� DATE Lq 'Z 23 l L <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 CALfqRNfA." <br /> Applicant' s Signature ( / <br /> Title Construction Manager 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 TAIT & Associates on behalf of 7 - Eleven Inc . Date <br /> Mailing Address 11280 Trade Center Dr . Rancho Cordova , 95742 <br /> Signature Daytime Phone <br /> 3of8 <br />