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SAN 10AQUIN <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 EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS <br />LETTER. <br />PROJECT CONTACT: <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, RULES AND <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT, <br />CONTACT PHONE # <br />Stephanie Charissa <br />916-343-3857 <br />FACILITY NAME: <br />FACILITY PHONE# <br />Triangle Plaza Tracy <br />FACILITY ADDRESS: <br />CROSS STREET: <br />3788 Tracy Blvd., Tracy, CA <br />95304 <br />1-205 <br />OWNER/OPERATOR: <br />PHONE: <br />3788 Tracy, LLC <br />408-638-1339 <br />CONTRACTOR NAME: <br />PHONE: <br />Walton Engineering, Inc. <br />916-343-3857 <br />CONTRACTOR ADDRESS: <br />CA LICENSE # <br />PO Box 1025, West Sacramento, CA 95691 <br />617238 /A, B, Haz <br />HAZARDOUS WASTE CERTIFICATE: <br />WORKERS COMP # <br />VYES <br />NO <br />SAMTWC10020101 <br />FIRE DISTRICT: <br />PERMIT <br /># <br />F24-0074 <br />South San Joaquin County Fire <br />Authority <br />TANK ID # <br />TANK SIZE <br />CHEMICAL <br />STORED <br />PROPOSED INSTALL DATE <br />1 <br />24K <br />87 GAS <br />TBD <br />2 <br />6K <br />E-85 <br />TBD <br />3 <br />15K <br />13-20 <br />TBD <br />4 <br />15K <br />91 GAS <br />TBD <br />❑ APPROVED <br />PPPROVED WITH <br />CONDITIONS ❑ DISAPPROVED <br />(see attachments) <br />PLAN REVIEWER'S NAME <br />�j <br />+' I� <br />DATE 10 130 1J,Lt <br />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 s <br />Title Operations Coordinator Date 08/09/24 <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 Stephanie Charissa <br />Mailing Address PO BOX 1025, West Sacramento, CA 95691 <br />Signature <br />3of8 <br />Daytime Phone 916-343-3857 <br />