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SAN , ,: M A U IN Environmental Health Department <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 /> OWNER/OPERATOR : 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 /> yo ' vl <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 AUGUST 1 , 2022 <br /> ❑ APPROVED APPROVED WITH CONDITIONS ❑ DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER' S NAME (',t` �j` DATE M (kQ I ( <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 IFORNIA. " <br /> Applicant's Signature <br /> Title OWNER Date MAY 101 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 /> SignatureDaytime Phone 916 708 -4999 <br /> 3of8 <br />