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SANJOAQUIN 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 /> Arch Road Travel Plaza <br /> FACILITY ADDRESS : CROSS STREET : <br /> 4850 S . 99 E Frontage Rd . Stockton , CA 95215 Arch Rd . <br /> OWNER/OPERATOR : PHONE : <br /> Five G Arch , LLC . C/O Jivtesh Gill 209 -491 -7445 <br /> CONTRACTOR NAME : PHONE : <br /> LC Services 559 -444 - 1730 <br /> CONTRACTOR ADDRESS : CA LICENSE # <br /> 3887 N Valentine Ave . Fresno , CA 93722 779267 <br /> HAZARDOUS WASTE CERTIFICATE : WORKERS COMP # <br /> X YES NO C69980430 <br /> FIRE DISTRICT : PERMIT # <br /> City of Stockton Fire Prevention BP21 -03874 <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 1 151000 Gas - RUL <br /> 2 71500 Gas - PUL <br /> 3 71500 Diesel <br /> ❑ APPROVED APPROVED WITH CONDITIONS ❑ DISAPPROVED <br /> ee attachments ) , <br /> PLAN REVIEWER 'S NAME < y— DATE <br /> APPLICANT MUST PERFORM ALL WORK INA 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 James Otto <br /> Title Project Coordinator - LC Services Date 9/9/2022 <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 Date 9/9/2022 <br /> Mailing Address 3887 N Valentine Ave <br /> Signature J ames Otto Daytime Phone 559444 - 1730 <br /> 3 of 8 <br />