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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: CONTACT PHONE# <br /> Sarah Jablonsky-Construction Manager 916-373-1165 <br /> FACILITY NAME: FACILITY PHONE# <br /> Charter Way 76 <br /> FACILITY ADDRESS: CROSS STREET: <br /> 1720 South Fresno Ave. W. Charter Way/State Route 4 <br /> OWNER/OPERATOR: PHONE: <br /> Charter Way Holdings LLC <br /> CONTRACTOR NAME: PHONE: <br /> Walton Engineering, Inc. 916-373-1165 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> PO Box 1025, West Sacramento, CA 95691 617238 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> YES NO 9113339 <br /> FIRE DISTRICT: PERMIT# <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 1 20,000 gal 87 Gasoline <br /> 2 12,000 gal 91 Gasoline <br /> 3 8,000 gal Diesel <br /> ❑APPROVED PPROVED WITH CONDITIONS ❑DISAPPROVED <br /> ra(schments) <br /> PLAN REVIEWER'S NAME �_ -*" L� � _ -_—� DATE IZ <br /> APPLICANT MUST PERFORM ALL WORK IN ACC DAN WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,RULES AND <br /> SAN JOAQUIN COUNTY ENVIRON -TFT15rEPARTMENT. 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 Rqtf�AIV11l1V��&A4 <br /> Title Sarah Jablonsky�- onstrucYi6r Manager Date 04/19/21 <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 Sarah Jablonsky-Construction Manager Date 04/19/21 <br /> Mailing Address PO Box 1025, West Sacramento, CA 95691 <br /> Signature Daytime Phone 916-373-1165 <br /> 3of8 <br />