Laserfiche WebLink
SA N J O A Q U I N 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 /> James Otto 559 -444 - 1730 <br /> FACILITY NAME : FACILITY PHONE# <br /> West Ln Chevron 209 -472 - 1639 <br /> FACILITY ADDRESS : CROSS STREET : <br /> 4747 West Ln , Stockton , CA 95210 Bianchi Rd <br /> OWNER/OPERATOR : PHONE : <br /> Ravinder Singh 209 - 992 - 1735 <br /> CONTRACTOR NAME : PHONE : <br /> LC Services 559 -444- 1730 <br /> CONTRACTOR ADDRESS : CA LICENSE # <br /> 3887 N Valentine Ave , Fresno , CA 93722 #779267 A , B , C10 , C21 , HAZ <br /> HAZARDOUS WASTE CERTIFICATE : WORKERS COMP # <br /> V YES NO C68629962 <br /> FIRE DISTRICT : PERMIT # <br /> Stocton CA BP20 -02854 <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> MOM TBD <br /> 12o-000 TBD <br /> 8 000 Diprpl TBD <br /> ❑ APPROVED APPP ED WITH CONDITIONS ❑ DISAPPROVED <br /> ee a ents ) j J <br /> PLAN REVIEWER' S NAME DATE <br /> APPLICANT MUST PERFORM ALL RK A DANCE 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 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 Signature % 0--V 6 Z; <br /> Title LC Services - Project Coordinator Date 7/8/2021 <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 LC Services - James Otto Date 7/8/2021 <br /> Mailing Address 3887 N Valentine Ave , Fresno , CA 93722 <br /> SignatureDaytime Phone 559-444- 1730 <br /> 3 of 8 <br />