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SAN10 A Q U 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 /> Chris Brown/ PM Design (707) 787-6062 <br /> FACILITY NAME: FACILITY PHONE# <br /> C-Store w/ 76 Fuel Island <br /> FACILITY ADDRESS: CROSS STREET: <br /> 141 E. Harney Ln., Lodi, CA 95240 Stockton St. <br /> OWNER/OPERATOR: PHONE: <br /> DN Partners, LLC. (916) 807-4076 <br /> CONTRACTOR NAME: PHONE: <br /> MDSM Corporation (562) 644-2787 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 12404 Brookshire Ave. 988467 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> X YES NO 1096041 <br /> FIRE DISTRICT: PERMIT# 20181853-20181856 <br /> Lodi Fire Department; 210 W. Elm Street, Lodi, CA 95240 (209) 333-6739 <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 1 20,000 Gal. Regular Unleaded Gasoline 2019 <br /> 2(Split) 8,000 Gal. Premium Unleaded Gasoline 2019 <br /> 3(Split) 12,000 Gal. Diesel 2019 <br /> ❑APPROVED .)(APPROVED WITH CONDITIONS ❑DISAPPROVED <br /> (see attachments) ' <br /> PLAN REVIEWER'S NAME W I DATE �1 12/��'1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQTJIN 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 CALIF/ NIA." L <br /> Applicant's Signature j/(J�—� <br /> Title Project Manager Date 4/16/2019 <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 DN Partners, LLC. Date 4/16/19 <br /> Mailing Address 10949 Trinity Parkway, C-274, Stockton, CA 95219 <br /> Signature Daytime Phone (916) 807-4076 <br /> 3 of <br />