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RECEIVED� + Jof� I ' i � + Environmental Health Department <br /> !( 1CI „H! I ' rUlia UCT 1 1 2021 <br /> ENVIRONMENTAL��g�e �HEALTH <br /> APPLICATION FOR UNDERGRBb STCJRATGE 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 /> M I ARCHITECTS, INC, J MR . MUTHANA IBRAHIM 925 -287 - 1174 x1 <br /> FACILITY NAME : FACILITY PHONE# <br /> MOUNTAIN HOUSE CHEVRON 408-813 -6416 <br /> FACILITY ADDRESS : ” CROSS STREET ; <br /> `l <br /> TRACY, CA 95377 IIAA444 <br /> OWNER/OPERATOR : PHONE : <br /> MR , JIM RUBNITZ (APPLICANT ) 408 -813- 6416 <br /> CONTRACTOR NAME : PHONE : <br /> t; �>� � ' _ �l� S U � ! <br /> CONTRACTOR ADDRESS : CA LICENSE # <br /> a 2c& Cp 1 UYUdo D9IVE ; RPWedo COR N� 14 Z391 ) Z <br /> HAZARDOUS WASTE CERTIFICATE : CO- '757Y4 WORKERS COMP # <br /> _ C YES NO q 2 ( Z <br /> FIRE DISTRICT: PERMIT # <br /> SOUTH SAN JOAQUIN COUNTY FIRE AUTHORITY � l � v � 7 `l <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 1 20 . 000 GALLONS REGULAR UNLEADED 09- 15-21 <br /> 2 10 non , AI I SNS PREMIUM UNLEADED 09- 15-21 <br /> 3 10 . 000 GALLONS DIESEL 09- 15-21 <br /> ❑ APPROVED APPROVED WITH CONDITIONS 0 DISAPPROVED <br /> (see attachments ) DD,, <br /> PLAN REVIEWER' S NAME DATE U " I0 - nLr(� 2 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE 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 " 1 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 C <br /> ALI <br /> FORNIA. " <br /> Applicant' s SignatureG <br /> Title OWNER Date IAC <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 MR . JIM RUBNITZ Date z4otc? <br /> Mailing Address 1,7610 BLANCWD DRIVE MONTE- SERENO CA 95030 <br /> Signature - Daytime Phone 408-813-6416 <br /> 3of8 <br />