Laserfiche WebLink
DocuSign Envelope ID:618BCOD1-3A2D-412B-BA33-27E602E49359 <br /> 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 /> Sandy Mann 925-446-0361 <br /> FACILITY NAME: FACILITY PHONE# <br /> Airport Petroleum, LLC 925-446-6806 <br /> FACILITY ADDRESS: CROSS STREET: <br /> 4607 S. Airport Way Stockton, CA 95206 Sperry Rd. <br /> OWNER/OPERATOR: PHONE: <br /> Charanjiv Dhaliwal 925-446-0102 <br /> CONTRACTOR NAME: PHONE: <br /> Town & Country Contractors, Inc. <br /> 916-636-9500 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 3206 Luyung Dr. RANCHO CORDOVA, CA 95742 238112 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> YES NO 9218782 <br /> FIRE DISTRICT: Stockton Fire Dept. PERMIT# BP23-00105 <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> See Attached Sheet <br /> ❑APPROVED ❑APPROVED WITH CONDITIONS ❑DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE bo 1 <br /> APPLICANT MUST PERFORM ALL WO IN ACCORDAVE 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 CA P"Aldh.dby: <br /> Applicant's Signature Charanjiv Dhaliwal <br /> Title President 06C3132D37C4493... Date 11/22/2023 <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 Charanjiv Dhaliwal Date <br /> Mailing Address 2190 Meridian Park Blvd. suite G Concord, CA 94520 <br /> Signature DO uftnedby` Daytime Phone 925-446-6806 <br /> Charanjiv Dhaliwal <br /> OOC3132D37C4493... <br /> 3 of 8 <br />