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SAN jOAQUIN <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 IF 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: CONTACT PHONE# <br /> Ryan Bharucha, Barghausen Consulting Engineering, Inc. (425)251-6222; rbharucha@barghausen.com <br /> FACILITY NAME: FACILITY PHONE# <br /> ARCO ampm NIA-new <br /> FACILITY ADDRESS: CROSS STREET: <br /> 6009 N. EI Dorado St., Stockton 95207 W. Swain Rd. <br /> OWNER/OPERATOR: PHONE: <br /> Grin Investments, Inc. (916)636-9500 <br /> CONTRACTOR NAME: PHONE: <br /> Town&Country Construction (916)636-9500 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 3206 Luyung Drive 238112 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> YES NO State Fund#9218782 <br /> FIRE DISTRICT: PERMIT* BP17-02430 <br /> City of Stockton Fire Department <br /> BOARD OF EQUALIZATION W--PENDING <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 2;a - 2.0 Dial remium Gasoline <br /> 8.000 gal Dpspl <br /> L APPROVED PPROVED WITH CONDITIONS _:DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME � l a M(3L n -)-O DATE (o— I q'SOI R <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. RULES <br /> AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES <br /> THE FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED., I SHALL NOT <br /> EMPLOY 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 SignatuI <br /> Title (C- - 1) Date <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 1 V�1�A�2 TA-� Q t K) (�tl Date R�- 2�y I <br /> Mailing Address A-fJILO' W, 1^^60 QdN OL3 .- <br /> Signatur Daytime Phone 7 2-Lf O] i7 <br /> ?Uf8 <br />