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SA N JOAQUIN Environmental Health Department <br /> COUNTY <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 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 : CONTACT PHONE # <br /> Jesse Diaz 405 -687- 1060 <br /> FACILITY NAME : FACILITY PHONE# <br /> Love' s Travel Stop - Ripon ( 209 ) 599- 0740 <br /> FACILITY ADDRESS : CROSS STREET : <br /> 1553 Colony Rd , Ripon , CA 95366 <br /> OWNER/OPERATOR : PHONE : <br /> Jesse Diaz 405 -687 - 1060 <br /> CONTRACTOR NAME : PHONE : <br /> Western Pump Inc 619 -239 - 9988 <br /> CONTRACTOR ADDRESS : CA LICENSE # <br /> 3235 F Street San Diego , CA 92102 673853 <br /> HAZARDOUS WASTE CERTIFICATE : WORKERS COMP # <br /> X YES NO WSD503615102 <br /> FIRE DISTRICT : PERMIT # <br /> Ripon Consolidated Fire Department ( Called for # 11 - 23 -20 ) <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> T-6 3 -----Gasoline 1 4 -21 <br /> 306000 Bio- Di <br /> T-8 301000 Diesel 1 4-21 <br /> ❑ APPROVED ,APPROVED WITH CONDITIONS ❑ DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER' S NAME DATE I J111. 1291 <br /> APPLICANT MUST PERFORM ALL WORK CCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED . , I SHALL NOT EMPLOY <br /> ANY PERSON IN SUCH A MANNER AS TO BEC E SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> CONTRACTOR'S HIRING OR SUBCONTRACTIN SIGNATURE CERTIFIES THE FOLLOWING " I CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WO FOR WHI H T PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF C FORNIA." <br /> Applicant' s Signature f_ Jamie Barnes HFA <br /> Title Date 10 -4 -2021 <br /> Indicate the responsible party'ta 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 Jamie Barnes Date 10 -4 -2021 <br /> Mailing Ads 1705 WA Blvd Suite 3 Bentonville AR 72712 <br /> Address . <br /> Signature Daytime Phone 580 - 371 - 1896 <br /> 3 of 8 <br />