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SAN JOAQUIN 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: <br /> 1231 North Main Street Manteca, CA 95336 West Louise Ave <br /> OWNER/OPERATOR: PHONE: <br /> Manteca Chevron 209-595-07 <br /> CONTRACTOR NAME: PHONE: <br /> B&T Service Station Contractors 805-929-/94,4 ext 1002 <br /> CONTRACTOR ADDRESS: CA LICENPt <br /> 630 South Frontage Road, Nipomo, CA 93444 902Q341, Fr#E1%V1ED_ <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> xxx YES NO 985282017 JUL d 2018 <br /> FIRE DISTRICT: PERMIT# <br /> ENVIRONMENTAL HEALTH <br /> ---- -- -- -- -- 1. <br /> PARTMENT <br /> TANK ID# TANK SIZE CHEMICA V STORED PROPOSED INSTALL DATE <br /> 1 20,000 Gallon Regular Unleade 7/12/2018 <br /> 2A 12,000 gallon Premium 7/1212018 <br /> 2B 8,000 gallon Diesel 7,'12!2018 <br /> ❑APPROVED 0 APPROVE WITH CONDITIONS ❑DISAPPROVED <br /> (see a chments) <br /> PLAN REVIEWER'S NAME ZDATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WI H 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 TWE 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 STATURE CERTIFIES THE FOLLOWING "1 CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PE MIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> Applicant's Signature r <br /> Title Project Coordinator Date 6/14/2018 <br /> Indicate the responsible parry 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 6/14/2018 <br /> Mailing Address 630 South Frontage Rod,Nipomo, CA 93444 <br /> Signature Daytime Phone 805-929-8944 ext 1002 <br /> 3of8 <br />