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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <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 EXTENSON MAY BE GRANTED BY EHD UPON RECEIPT OF THIS <br />LETTER. <br />PROJECT CONTACT: <br />CONTACT PHONE # <br />Sarah Jablonsky-Construction Manager <br />916-373-1165 <br />FACILITY NAME: <br />FACILITY PHONE# <br />Edgewood Commercial Center <br />FACILITY ADDRESS: <br />CROSS STREET: <br />4600 S. Corral Hallow Rd., Tracy, CA 95377 <br />Middlefield Dr. <br />OWNER/OPERATOR: <br />PHONE: <br />Harpreet Singh & Varinder Pal Singh <br />CONTRACTOR NAME: <br />PHONE: <br />Walton Engineering, Inc. <br />916-373-1165 <br />CONTRACTOR ADDRESS: <br />CA LICENSE # <br />PO Box 1025, West Sacramento, CA 95691 <br />617238 <br />HAZARDOUS WASTE CERTIFICATE: <br />COMP # <br />&WORKERS <br />YES NO <br />9113339 <br />FIRE DISTRICT: <br />PERMIT # <br />South San Joaquin County Fire Authority <br />COM21-0110 <br />TANK ID # TANK SIZE <br />CHEMICAL STORED PROPOSED INSTALL DATE. <br />1 25,000 gal <br />87 Gasoline <br />2 10,000 gal <br />91 Gasoline/Split <br />3 10,000 gal <br />Diesel/Split <br />❑ APPROVEDi <br />APPROVED WITH CONDITIONS <br />❑ DISAPPROVED <br />(see attachments) <br />PLAN REVIEWER'S NAME T <br />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'] 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 />Applicant's Signature gIALE%' (��IN,1 w&yyl <br />Title Sarah Jablonsky - Construction Manager Date 3/4/21 <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 Sarah Jablonsky - Construction Manager <br />Mnilinn ArlrlraSS PO Box 1025, West Sacramento, CA 95691 <br />Signature � hl Km <br />3 of 8 <br />Date 3/4/21 <br />Daytime Phone 916-373-1165 <br />