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0 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN 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 DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR, A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. <br />PROJECT CONTACT: <br />CONTACT PHONE # <br />David E. Painter <br />(425) 251-6222 <br />FACILITY NAME: <br />FACILITY PHONE# <br />Costco Retail Fueling Station <br />TBD <br />FACILITY ADDRESS: <br />CROSS STREET: <br />Highway 120 and Daniels Street, Manteca, CA <br />OWNER/OPERATOR: <br />PHONE: <br />Kim Sanford <br />(425) 313-8100 <br />CONTRACTOR NAME: <br />PHONE: <br />TBD <br />CONTRACTOR ADDRESS: <br />CA LICENSE # <br />HAZARDOUS WASTE CERTIFICATE: <br />WORKERS COMP # <br />YES NO <br />FIRE DISTRICT: <br />PERMIT # <br />BOARD OF EQUALIZATION # <br />TANK ID # TANK SIZE <br />CHEMICAL STORED PROPOSED INSTALL DATE <br />1 30,000 -Gallon <br />Unleaded Gasoline January 2008 <br />2 30,000 -Gallon <br />Unleaded Gasoline January 2008 <br />3 30,0Go-Gallon <br />Premium Gasoline January 2008 <br />Q APPROVED L(APPROVED WITH CONDITIONS ❑ DISAPPROVED <br />PLAN REVIEWER'S NAME / <br />(see attachments) ,f% <br />� d4,A DATE �'� oe <br />AF'F'LIUAN I Muo 1 rt_mrvrtm ALL vvvr%r% 111 ♦ 1 1 1 1 ­s..ns,-...,.,,,, .,,.,..... _ _ ... _ - -- <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 PERFORMANCE <br />OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, l SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature <br />Title Director of Real Estate Development Date 9 I -1-k 10:1 <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 David E. Painter Date q1 2_q107 <br />Mailing Add ss ,1sz15 - 7znd Aventn, xent, WA 98032 <br />Signature <br />Daytime Phone (425) 251-6222 <br />Revised 8/4146 3 12919.003.pdf <br />