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M 1w, <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: CONTACT PHONE# <br /> Pete Tobin (425) 251-6222 <br /> FACILITY NAME: FACILITY PHONE# <br /> Arco AM/PM T.B.D <br /> FACILITY ADDRESS: CROSS STREET: <br /> SEC of West Valpico Rd South Tracy Blvd <br /> OWNER/OPERATOR: PHONE: <br /> Pacific West Petroleum Inc . (925) 689-0557 <br /> CONTRACTOR NAME: PHONE: <br /> town and Country Contractors Inc 916-636-9500 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 3181 Luyung Dr Rancho Cordova, Ca 238112 A, B Haz <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> X YES NO 0003128-2011 <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 1 20, 000 87 Gasoline 9/29/2011 <br /> 12 , 000 91 Gasoline 9/29/2011 <br /> 3 10 , 000 Diesel 9/29/2011 <br /> ❑APPROVED )(APPROVED WITH CONDITIONS ❑DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE (Q OFN <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br /> CERTIFIES THE FOLLOWING " CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED, I SHALL EMPLOY P ONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> Applicant's Signature W <br /> Title Senior Project Manager Date 7/1/2011 <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 /> et <br /> Name4Wq4#44� /N fE �'1'�� Date 7/1/2011 <br /> Mailing Address 3400 Pass Road, Concord, CA 94519 <br /> Signature Daytime Phone (925) 689-0557 <br /> Revised 07/22/10 3 <br />