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10/13/2017 8:53PM FAX @0001/0001 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAG I TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGRO}ND STORAOE TANKS IS ONLY V UD 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 S NT TO END REQUESTING THIS EXTENSION THIRTY DAY$ <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY END UPON RECEIPT OF THIS LETTER. <br /> PROJECT CONTACT: CO TACT PHONE# <br /> JR BEARD C/o LHB&ASSOCIATES 05-540-5240 <br /> FACILITY NAME: FACILITY PHONE# <br /> MANTECA CHEVRON T.8.D. <br /> FACILITY ADDRESS: CROSS STREET: <br /> 1490 SOUTH MAIN STREET, MANTECA CA 95337 QUINTAL ROAD <br /> OWNERIOPERATOR: PHONE: <br /> (ANNIE)GURPREET SANDHU 925-785-2000 <br /> CONTRACTOR NAME: PH NE: <br /> WALTON ENGINEERING, INC. 916-373-1165 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> PO BOX 1025,W. SACRAMENTO, CA 95691 617238 <br /> HAZARDOUS WASTE CERTIFICATE: WO qKERS COMP# <br /> YES x NO 9113339-2016 <br /> FIRE DISTRICT: PERMIT# <br /> MANTECA FIRE DEPARTMENT 16-3684 <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 1 20,000 GALLON REGULAR UNLEADED 1D1112017 <br /> 2A 8,000 GALLON PREMIUM UNLEADED ID1112017 <br /> 28 12,000 GALLON DIESEL 1011/2017 <br /> 0 APPROVED APPROVED WITH CONDI rioNs 0 DISAPPROVED <br /> see I1atttachments) <br /> PLAN REVIEWER'S NAME v4G+ la 121 DATE <br /> APPLICANT MUST PERFORM ALL WORK IN PCCCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br /> CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE PERFORMANCE F THE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED,I SHALL EMPLOY PEWONS S�B `CT 7�YORKER'S COMPENSATION LAWS OF CALIFORNIA" <br /> Applicant's Signature __, -- <br /> Title PRINCIPAL 7 Date111 41 47 <br /> Indicate the responsible party to be billed for additional EHD staff time expeAded beyond the 8-hour minimum installation <br /> payment.The party must acknowledge this responsibility far the additional b111i g by signature and date below. <br /> Name (ANNIE)GURPREETSANDHU Date <br /> Mailing Address E•S G ILL T RRACE,i DUBLIN CA 04666 <br /> Signature aytlme Phone 025785-2000 <br /> i <br /> Revised 7/26/2016 3 <br />