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SA N J0 A QU I N 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 Contractor 805-929-8944 ext 1002 <br /> FACILITY NAME: FACILITY PHONE# <br /> Manteca Chevron 209-595-0787 <br /> FACILITY ADDRESS: CROSS STREET: Q <br /> 1231 North Main Street Manteca CA 95336 West Louise Ave <br /> OWNER/OPERATOR: PHONE: <br /> �a oo F-- <br /> Manteca Chevron 209-595-0787 z <br /> CONTRACTOR NAME: PHONE: L�a W <br /> B&T Service Station Contractors 805-929-8944 ext 1002 =� cr <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> CL <br /> 630 South Frontage Road, Nipomo, CA 93444 902034ZZ111 ¢ W <br /> spa <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> xxx YES NO 90685282017 <br /> rr <br /> FIRE DISTRICT: PERMIT# <br /> City of Manteca Fire Department 2016-00 0458 <br /> TANK ID# TANK SIZE CHEMICAL STORO PROPOSED INSTALL DATE <br /> 1 20,000 Gallon Regular Unleaded 7/12/2018 <br /> 2A 12,000 gallon Premium 7/12/2018 <br /> 2B 8,000 gallon Diesel 7/12/2018 <br /> ❑APPROVED ❑APPROVED OTH CONDITIONS ❑DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE TH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP MENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE O 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 THI,S�PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." ��// <br /> Applicant's Signature <br /> Title Project Coordi ator f Date 7/23/2018 <br /> Indicate the responsible party to be bX(ed for additional EHD staff time expended beyond the 8-hour minimum installation <br /> payment.The party must acknowled e this responsibility for the additional billing by signature and date below. <br /> Name B&T Service Station C tractors Date 6/14/2018 <br /> Mailing Address 630 South Yrontage Road, Nipomo, CA 93444 <br /> Signature Daytime Phone 805-929-8944 ext 1002 <br /> 3 of 8 <br />