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( A I n f 1 I ' ( � p nvironmental Health Department <br /> — G O U 6N� Tt�YU--- <br /> Of `� <br /> rvV 0 ry MtI A L <br /> r + P GE TK INSTALLATION PERMIT <br /> APPLICATION FOR UNDERGR6U D t 'O <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 /> Chandra Miehe on behalf of 7- Eleven , Inc 916 - 669 - 1823 <br /> FACILITY NAME : FACILITY PHONE# <br /> 7- Eleven , Inc #41187 <br /> FACILITY ADDRESS : CROSS STREET : <br /> 1829 N . Wilson Way Bradford <br /> OWNER/OPERATOR : PHONE : <br /> 7 - Eleven , Inc . 916 -742-0232 <br /> CONTRACTOR NAME , PHONE : <br /> Walton Engineering 916 -826 - 3080 <br /> CONTRACTOR ADDRESS : CA LICENSE # <br /> P . O . Box 1025 West Sacramento , CA 95691 617238 <br /> HAZARDOUS WASTE CERTIFICATE : WORKERS COMP # <br /> X YES NO 9113339 <br /> FIRE DISTRICT : PERMIT # <br /> Stockton Fire Dept , BP20-01804 <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> # 1 20 ,000 Gallons Regular Unleaded Fuel <br /> #2 8 , 000 Gallons Premium Unleaded Fuel <br /> #3 12 ,000 Gallons Diesel Fuel <br /> ❑ APPROVED APPx ED WITH CONDITIONS ❑ DISAPPROVED <br /> 116'eue a achments ) <br /> PLAN REVIEWER'S NAME ° j" LVI, _ DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCoRDAqCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALItt40PARTMENT, 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 01 CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT XO WORKER'S <br /> COMPENSATION LAWS OF f:AI IFORNIA " <br /> Applican+' s cinnnn oro <br /> Title , o h-Q r 1Z O I4?, Date _ / O — O r - 2. 0 <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 7- Eleven , Inc c/o Crystal Justice Date 04- 30-2020 <br /> Mailing Addr S PO Box 711 Attn : Gasoline Compliance <br /> Signature I Daytime Phone 916-742 -0232 <br /> i <br /> 3of8 <br />