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SAN.dOAQUIN COUNTY Environmental Health Department APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. PROJECT CONTACT: CONTACT PHONE # Glenn Paredes - B&T Service Station Contractor 805-929-8944 ext 1002 FACILITY NAME: FACILITY PHONE# Manteca Chevron 209-595-0787 FACILITY ADDRESS: CROSS STREET: 00 1231 North Main Street Manteca CA 95336 West Louise Ave o OWNER/OPERATOR: PHONE: C<31 Manteca Chevron 209-595-0787 UJ CONTRACTOR NAME: PHONE: B&T Service Station Contractors 805-929-894 xt 1002 - CONTRACTOR ADDRESS: CA LICENSE # 630 South Frontage Road, Nipomo, CA 93444 902034 HAZARDOUS WASTE CERTIFICATE: WORKER COMP # xxx YES NO 906y282017 FIRE DISTRICT: PERMIT # TANK ID # TANK SIZE CHEMICALATORED PROPOSED INSTALL DATE 1 20,000 Gallon Regular Unleaded/7/12/2018 2A 12,000 gallon Premium 7/12/2018 28 8,000 gallon Diesel 7/12/2018 ❑ APPROVED ❑ APPROVE WITH CONDITIONS ❑ DISAPPROVED (see achments) PLAN REVIEWER'S NAME DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCETH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA MINT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF HE WORK FOR WHICH THIS PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOM SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SI NATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEIRMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." -11 Applicant's Signature Title Project Coordinator Date 6/14/2018 Indicate the responsible party to be billed for apditional EHD staff time expended beyond the 8 -hour minimum installation payment. The party must acknowledge this re onsibility for the additional billing by signature and date below. Name B&T Service Station Contractors Mailing Address 630 South Signature , Nipomo, CA 93444 3 of 8 Date 6/14/2018 Daytime Phone 805-929-8944 ext 1002 IJ - Q LU 2 J I¢— Z W Z 7 Z W I• -- Z W Q ci: LU 0