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SAN JOAQUIN 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 15 SENT TO EHO REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME.ONE YEAR EXTENSION MAY BE GRANTED BY EHO UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. PROJECT CONTACT: SUZANNE RUSIT CONTACT PHONE# (925) 313-9700 FACILITY NAME: SAFEWAY STORE #2707 FACILITY PHONEY FACILITY ADDRESS: 6425 PACIFIC AVE., STOCKTON CROSS STREET: DOUGLAS ROAD OWNER/OPERATOR SAFEWAY, INC. PHONE: (925) 467-2078 CONTRACTOR NAME: PHONE T.B.D. CONTRACTOR ADDRESS: CA LICENSE# CLASS: TY TK HQ 44-040801 TANK ID# TANK SIZE CHEMICALS TO BE SPORED PROPOSED INSTALL DATE 20,000 GALLONS REGULAR UNLEADED DECEMBER 2003 20,000 GALLONS PREMIUM UNLEADED/DIESEL DECEMBER 2003 _]APPROVED A4PROVED WITH CONDITIONS _DISAPPROVED (see attachment with conditions) PLAN REVIEWER'S NAME DATE APPLIGANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN.I-, QUIN COUNTY ORDINANCES.STATE LAWS.AND RULE'S AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THC FOLLOWING."I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrr IS ISSUED,I SHALL NOr EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRA�OR'S HIRD1G OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PER 1'riS SSaED.I J 1ALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE—_ JOB CAPTAIN —DATE 09/11 03 Indicate the responsiblerty to bill o dditionai EHD staff time expended beyond the 8 hour minimum installation payment. The pa must a kn ed,a this responsibility for the additional billing by signature and date below. Name SAFEWAY INC. — TODD PARADIS Mailing Address 5918 STONERIDGE MALL RD., PLEASANTON, CA 94588 Day Phone Number925) 7-2078 _ ....... ._..... _.----- Signature /IIu K Date-...-.._ / -----------— -- -- EH 23 008(Rev 3115102) 4