Laserfiche WebLink
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SA <br /> AI 10 A (� I I I AI Environmental Health Department <br /> COJUNTY ' \ <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 /> James Otto 5594444730 <br /> FACILITY NAME : FACILITY PHONE# <br /> Grappa Market Shell <br /> FACILITY ADDRESS : CROSS STREET : <br /> 710 N Jacktone Rd Canal Dr <br /> OWNER/OPERATOR : PHONE : <br /> Gulbahar Saini 312 - 9124833 <br /> CONTRACTOR NAME : PHONE : <br /> LC Services 559444 - 1730 <br /> CONTRACTOR ADDRESS : CA LICENSE # <br /> 3887 N Valentine Ave 779267 <br /> HAZARDOUS WASTE CERTIFICATE : WORKERS COMP # <br /> X YES NO C69980430 <br /> FIRE DISTRICT: PERMIT # <br /> City of Ripon Fire Department Not Required <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 16 000 Gas RUL <br /> 2 6 000 E85 <br /> 3 125000 Gas PUL <br /> 4 1 8 000 Diesel <br /> ❑ APPROVED ❑ APPROVED WITH CONDITIONS ❑ DISAPPROVED <br /> (see attachments) <br /> DATE 11V I U2Z <br /> PLAN REVIEWER' S NAME <br /> APPLICANT MUST PERFORM ALL WORK IN V4.GjRDANCE 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 .31 <br /> Applicant' s Signature <br /> Title Project Coordinator Date 1 /21 /2022 <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 James Otto - LC Services (For Installation of System) Date 1 /21 /22 <br /> Mailing Address 3887 N Valentine Ave <br /> Signature Daytime Phone 5594444730 <br /> 3of8 <br />