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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: JEFFREY LEE c/o eda CONTACT PHONE# 805) 546-2050 <br /> FACILITY NAME: RALEY's FUEL STATION 3356 FACILITY PHONE# <br /> FACILITY ADDRESS:4255 E. MORADA LANE CROSS STREET: FRONTAGE ROAD & HP Y. 99 <br /> OWNER/OPERAT(1u• MIKE GATES C/o RALEY'S PHONE: (916) 373-3333 <br /> CONTRACTOR NAME: PHONE: <br /> T.B.D. <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> HAZARDOUS WASTE CERTIFICATE: YES NO WORKERS COMP# <br /> FIRE DISTRICT: CITY OF STOCKTON FIRE PREVENTION PERMIT# <br /> BOARD OF EQUALIZATION# SRY JHF 98-031849 <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 1 20.000 GALLONS REGULAR UNLEADED FSB. 2006 <br /> 2A 121,000 GALLONS PREMIUM UNLEADED FEB. _2006 <br /> 2B 101,000 GALLONS AUTO DIESEL FEB. 2006 <br /> ❑APPROVED ❑ APPROVED WITH CONDITIONS ❑ DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE 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 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA."CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING`I CERTIFY THAT IN THE PERF NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL <br /> EMPLOY PERSONS SUBJECT TO RKER' PENSATION WS OF CALIFORNIA." <br /> APPLICANT'S SIGNAT eC <br /> PROJECT MANAGER EY EE C/o - esign pro essionals <br /> TITLE DATE /0•$•05 <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8-hour <br /> minimum installation payment.The party must acknowledge this responsibility for the additional billing <br /> by signature and date below. <br /> Name MIKE GATES c/o RALEY'S Date 10 A Lo tj <br /> Mailing Addre WET APITOL AVE.,, WEST SACRAMENTO,, CA 95605 <br /> Signature Daytime Phone (916) 373-3333 <br /> C. REQUIRED SUBMITTALS <br /> - 3 - <br />