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SA N 'J O A Q U IN Environmental Health Department <br /> - COUNTY— <br /> APPLICATION <br /> OUNTYAPPLICATION 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 /> Grace Esplin on behalf of 7-Eleven , Inc. 916. 669. 1838 <br /> FACILITY NAME: FACILITY PHONE# <br /> 7-Eleven, #41258 <br /> FACILITY ADDRESS: CROSS STREET: <br /> 1233 E. Dr. Martin Luther King Jr. Blvd . S. Airport Wy. <br /> OWNER/OPERATOR: PHONE: <br /> 7-Eleven , Inc. 916.742 . 0232 <br /> CONTRACTOR NAME: PHONE: <br /> Walton Engineering Inc. 916 372- 1888 <br /> CONTRACTOR ADDRESS: CA LICENSE # <br /> 3900 Commerce Dr. West Sacramento , CA. 95691 617238 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP # <br /> X YES NO 9113339 <br /> FIRE DISTRICT: PERMIT # <br /> City of Stockton BP20-05193 <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 28K RUL04/2021 <br /> PUL n4/20213 12K DSL n4/2021 <br /> ❑ APPROVED APPROVED WITH CONDITIONS ❑ DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER' S NAME �ib./o. 1..G .�Y�>rL DATE _719/20Z / <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 C FOR <br /> Applicant's Signature <br /> Title Construction an per Date Fin PXT� <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 �(" J20 <br /> Mailing <br /> MailingAddres P .O . Box 711 Attn : Gasoline Compliance <br /> Signature Daytime Phone 916.742 . 0232 <br /> 3of8 <br />