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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 MAYBE 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 /> A & S Engineering/Robert Velasco 661 -250-9300 <br /> FACILITY NAME: FACILITY PHONE# <br /> Arco AM / PM - BP Fuel Dispensing Facility 281 -995-5679 <br /> FACILITY ADDRESS: CROSS STREET: <br /> 2510 South State Highway 99 & Frontage Road <br /> San Joa uin Con CA 95205 Mariposa Road <br /> OWNER/OPERATOR: PHONE: <br /> Arco AM / PM - BP Attn . Mr. Kenneth Wold / Owner <br /> 2626 Cobble Rock Way, EI Dorado Hills CA 95762 281 995-5679 <br /> CONTRACTOR NAME: PHONE: <br /> Savidge Construction Inc. 530-622-1982 <br /> CONTRACTOR ADDRESS: CA LICENSE # <br /> 4401 Sonja Court, Placerville CA 95667 755898 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP # <br /> YES No 17600013768191 <br /> FIRE DISTRICT: PERMIT # <br /> San Joaquin County Fire BP- 1905173 <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 1 25,000 87 Product To be determined <br /> 2 (Split UST) 12,000/10,000 91 ProductlDlesel Product To be determined <br /> 3 81000 DEF Product To be determined <br /> 4/5 20,000/20,000 D'leeel/Diesel To be determined <br /> D APPROVED PPPROVED WITH CONDITIONS U DISAPPROVED <br /> �� <br /> (see attachments) <br /> PLAN REVIEWER'S NAME 0% DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCEITH 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 IIE WORK FOR WHICH THIS PERMIT IS ISSUED., I SHALL NOT EMPLOY <br /> ANY PERSON IN SUCH A MANNER AS TO RECO SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> CONTRACTOR'S HIRING OR SUBCONTRACTING. IGNATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH TH. <br /> COMPENSATION LAWS OF CALIFORNIA." PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> Applicant's Signature <br /> Title Agent Date 12/13/2019 <br /> Indicate the responsible party to b "led for addili al EHD staff time expended beyond the 8-hour minimum installation <br /> payment. The party must acknowle ge this respop (lily for the additional billing by signature and date below. <br /> Name A & S Engineering/Robert Vela � Date 12/13/2019 <br /> Mailing Address 28405 Sand Canyo2KCad , Suite "B" , Canyon Country, CA 91387 <br /> Signature Daytime Phone 661 -250-9300 <br /> 3 of <br />