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SA N )O 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 /> A & S Engineering/Robert Velasco 661-250-9300 <br /> FACILITY NAME: FACILITY PHONE# <br /> Arco AM / PM - BP Fuel Dispensing Facility 661-250-9300 for this project <br /> FACILITY ADDRESS: CROSS STREET: <br /> 1243 West March Lane, Stockton CA 95215 Pershing Avenue <br /> OWNER/OPERATOR: PHONE: <br /> BP Products North America Inc. 661-250-9300 for this project <br /> CONTRACTOR NAME: PHONE: <br /> Town & Country Contractors Inc 916-636-9500 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 3206 Luyung Drive, Rancho Cordova CA 95742 238112 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> YES NO State Comp Ins Fund/9218782 <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 91 Product To be determined <br /> 3(Split UST) 10,000 Diesel Product To be determined <br /> ❑APPROVED �4�,APPROVED WITH CONDITIONS ❑DISAPPROVED <br /> see attachments) <br /> PLAN REVIEWER'S NAMEDATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCO ANCETH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA ML"NT,OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE OF HE WORK FOR WHICH THIS PERMIT IS ISSUED.,I SHALL NOT EMPLOY <br /> ANY PERSON IN SUCH A MANNER AS TO BECO SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> CONTRACTOR'S HIRING OR SUBCONTRACTING 03NATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THI RMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> Applicant's Signature <br /> Title Agent Date 7/1/2021 <br /> Indicate the responsible party to be billfor additional EHD staff time expended beyond the 8-hour minimum installation <br /> payment.The party must acknowledge is responsibility for the additional billing by signature and date below. <br /> Name A & S Engineering/Robert Velasco Date 7/1/2021 <br /> Mailing Address 28405 Sand Canyon Road, Suite"B", Canyon Country, CA 91387 <br /> Signature Daytime Phone 661-250-9300 <br /> 3 of 8 <br />