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SA N 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 /> Stig Werelius 707-774-8333 <br /> FACILITY NAME: FACILITY PHONE# <br /> Safeway 0055 Fuel <br /> FACILITY ADDRESS: CROSS STREET: <br /> 19533 S. Mountain House Parkway Byron Road <br /> OWNERIOPERATOR: PHONE: <br /> Safeway Inc. 925-226-5754 <br /> CONTRACTOR NAME: PHONE: <br /> B&T Service Station Contractors (805)929-8644 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 630 S Frontage Rd, Nipomo, CA 93444 902034 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> X YES NO <br /> UB2R220311 <br /> FIRE DISTRICT: PERMIT# <br /> French Camp McKinley Fire Protection District BP-2102543-44 <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 1 30,000 gal. Regular Unleaded 8/1/2021 <br /> 2 15,000 gal. (split) Premium Unleaded 8/1/2021 <br /> 3 15,000 gal. (split) Diesel 8/1/2021 <br /> ❑APPROVED APPROVED WITH CONDITIONS ❑DISAPPROVED <br /> attachments) <br /> PLAN REVIEWER'S NAME C DATE 2 <br /> APPLICANT MUST PERFORM ALL WORK IN AC CE 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"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 CALIFORNIA." <br /> Applicant's Signature LA�zdz-&� q. <br /> Title PRESIDENT VDate 11/08/2021 <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 CHRISTOPHER G FASSE Date 11/08/2021 <br /> Mailing Address 630 SOUTH FRONTAGE RD, NIPOMO, CA 93444 <br /> Signature �L2GQi, - �Cldd� Daytime Phone 805 929 8944 EXT 1001 <br /> 3of8 <br />