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SANJOAQUIN Environmental Health Department <br /> —COU NTY- <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 r7l -i- <br /> FACILITY ADDRESS: CROSS STREET: J <br /> 1231 North Main Street, Manteca, CA 95336 West Louise Ave W . <br /> r_ <br /> OWNER/OPERATOR: PHONE: "��: �a = z <br /> Manteca Chevron 209-595-0787 o Q <br /> NTS'-.A:12 <br /> CONTRACTOR NAME: PHONE: C; ZLL1 Cc <br /> < <br /> B&T Service Station Contractors 805-929-8944 ext 1002 Z LCL <br /> L1 <br /> CONTRACTOR ADDRESS: CA LICENSE# 0 C-. <br /> fr <br /> 630 South Frontage Road, Nipomo, CA 93444 902034 > <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# Z <br /> xxx YES NO 90685282017 t1J <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 10128/2018 <br /> 2A 12,000 gallon Premium 10/28/2018 <br /> 2B 8.000 gallon Diesel 10128/2018 <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 /> � <br /> Applicant's Signature <br /> Title Project Coordinator Date 10/112018 <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 630 South Frontage Road Nipomo,CA 93444 <br /> Signature Daytime Phone 805-929-8944 ext 1002 <br /> 3of8 <br />