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SANJOAQUIN <br /> Environmental Health Department <br /> C 0UNTl'..................... <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 /> Sammy Orlando 916 708-4999 <br /> FACILITY NAME: FACILITY PHONE# <br /> Big Boy Chevron <br /> FACILITY ADDRESS: CROSS STREET: <br /> 2226 Jackson Ave Elizabeth Ave <br /> OWNERIOPERATOR: PHONE: <br /> Sammy Orlando 916 708-4999 <br /> CONTRACTOR NAME: PHONE: <br /> JP Petroleum Service 916-372-5693 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 3065 Asante Lane, West Sacramento, 95691 #811471 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> A HAZ B X YES NO WSA506672300 <br /> FIRE DISTRICT: PERMIT# <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> #1 20K 87 UNLEADED AUGUST 1 ,2022 <br /> #2 10K 91 UNLEADED AUGUST 1,2022 <br /> #3 10K DIESEL B20 AUGUST 1,2022 <br /> ❑APPROVED ❑APPROVED WITH CONDITIONS ❑DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE <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 "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 A��7' <br /> " <br /> Applicant's Signature <br /> Title OWNER Date MAY 10, 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 Sammy Orlando Date 5-10-22 <br /> Mailing Address 2226 Jackson Ave Escalon, CA 95320 <br /> Signature l/riilt�� Daytime Phone 916 708-4999 <br /> 3of8 <br />