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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 /> Glenn Paredes - B&T Service Station Contractors 805-929-8944 ext 1002 <br /> FACILITY NAME: FACILITY PHONE# <br /> Manteca Chevron 209-595-0787 <br /> FACILITY ADDRESS: CROSS STREET: <br /> 1231 North Main Street, Manteca, CA 95336 West Louise Ave <br /> OWNER/OPERATOR: PHONE: _ <br /> Manteca Chevron 209-595-0787 ® IJ <br /> CONTRACTOR NAME: PHONE: W <br /> 2 <br /> B&T Service Station Contractors 805-929-8944 ekt°1W2 o J w <br /> CONTRACTOR ADDRESS: CA LICENSE# '" <br /> y a F cs, 1- <br /> 630 South Frontage Road, Nipomo, CA 93444 902034 a L!9 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# , o <br /> xxx YES NO 90685282017 z ClC-, <br /> p <br /> FIRE DISTRICT: PERMIT# <br /> City of Manteca 2018-00002512 <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 1A 20,000 gallon Regular Unleaded 10/28/2018 <br /> 2A 12,000 gallon Premium 10/28/2018 <br /> 2B 8,000 gallon Diesel 10/28/2018 <br /> ❑APPROVED ❑APPROVED WITH CONDITIONS ❑DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE <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 CALIFORNIA."/ <br /> Applicant's Signature 04��/0Q2QW'4w, <br /> Title Project Coordinato�/ Date 10/1/2018 <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 B&T Service Station Contractors Date 10/1/2018 <br /> Mailing Address 6330 South Frontage Road Nipomo,CA 93444 <br /> Signature cyXAjtofl AQ2QW,4-d- Daytime Phone 805-929-8944 ext 1002 <br /> 3 of 8 <br />