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SANJOAQUIN Environmental Health Department <br /> (71 ( ) Nl T Y <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 /> Gurpartap Singh 925 724 -8010 <br /> FACILITY NAME : FACILITY PHONE# <br /> Wilson Chevron <br /> FACILITY ADDRESS : CROSS STREET : <br /> 4343 Wlson Way , Stockton , CA 95765 E . McAllen Rd <br /> OWNER/OPERATOR: PHONE : <br /> Gurpartap Singh 925 724 - 8010 <br /> CONTRACTOR NAME : PHONE : <br /> Town and Country Contractors 530- 363 -0574 <br /> CONTRACTOR ADDRESS : CA LICENSE # <br /> 3206 Luyung Dr, Rancho Cordova , CA 95742 238112 A , B , C36 , D40 , Haz <br /> HAZARDOUS WASTE CERTIFICATE : WORKERS COMP # <br /> A HAZ B X YES NO 9218782 state fund <br /> FIRE DISTRICT: PERMIT # <br /> Waterloo-Morada Fire Dept SSG Z 2 + 002 C5 <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> N1 20K 87 UNLEADED AUGUST 1202 <br /> # 2 20k Split - 10K 91 UNLEADED AUGUST 1 , 2022 <br /> 43 20K Spld- 10K DIESEL AUGUST I , 2022 <br /> 44 p5 25K BK DIESEL DEF AUGUST I , 2022 AUGUST 1 , 2022 <br /> ❑ APPROVED APPROVED WITH CONDITIONS ❑ DISAPPROVED <br /> see attachments ) <br /> PLAN REVIEWER' S NAME to . DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACOR ANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS, RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAITH 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 �— <br /> Title OWNER Date MAY 512022 <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 6-hour minimum installation <br /> payment. The party must acknowledge %p responsibility for the additional billing by signature and date below. <br /> Name Gurpartap Singh Date 5- 5-22 <br /> Mailing Address P • O . Box 62 , Mountain House , CA 95391 <br /> Signature ���� ,/ — Daytime Phone 707 486-8894 <br /> 3 of 13 <br />