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SANJOAQUIN Environmental Health Department <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 /> Amarjit Khinda (209) 321-4134 <br /> FACILITY NAME: FACILITY PHONE# <br /> City Gas & Liquor (209) 647-4273 <br /> FACILITY ADDRESS: CROSS STREET: <br /> 16470 Cambridge Drive, Lathrop, CA 95330 Louise Ave. <br /> OWNER/OPERATOR: PHONE: <br /> Interstate A Enterprises, Inc. (209) 321-4134 <br /> CONTRACTOR NAME: PHONE: <br /> Elite IV Contractors (209) 461-6337 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 2535 Wigwam Dr., Stockton, CA 95205 1001331 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> N/A YES NO BNUWC0133392 <br /> FIRE DISTRICT: PERMIT# <br /> Lathrop-Manteca Fire Protection District 2016-0975 <br /> BOARD OF EQUALIZATION# <br /> TBD <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> TA0520817 <br /> TA0520819 Su er unleaded ASAP <br /> TA0520818 6,000 dallons Diesel <br /> ❑APPROVED PPROVED WITH CONDITIONS ❑DISAPPROVED <br /> p� (see attachments) <br /> PLAN REVIEWER'S NAME I "� �/C� DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, RULES <br /> AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES <br /> THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED., I SHALL NOT <br /> EMPLOY 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 CALIFOR IA" <br /> Applicant's Signature <br /> Title President Date Jan. 16, 2018 <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 Amarjit Khinda Date Jan. 16, 2018 <br /> Mailing Address 16470 Cambrid Dr. athrop, CA 95330 <br /> Signature Daytime Phone (209) 321-4134 <br /> 3of8 <br />