Laserfiche WebLink
03-11-97 11: 17 A'111 FFi)M 7:70 TRANS-MODESi3 F <br /> SAN JOAQU_N COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPL_TCATION FOR UNDERGROUND STORAGE TAt41C INSTALLATION PERMIT <br /> rxE APPLICATION FOR INSTALLATION OF t'NDERGROUND STCRAGE TANKS IS ONLY VALID FOR THE CALENDAR '!EAR IN WHICH IT HAS 3EEN ISSUED. <br /> A 0ER.M)T MAY 3E E%i ENDED :NT,] THE 0)(T CALFNOAA YEAR IF A LETTER :S SENT TO PHS•EHO REQUEST:NG THIS EX=-=$ICN THIRTY DAYS <br /> PRIOR rC THE _ND OF THE CALENDAR TEAR. A CNE TINE, ONE YEAR EXTENSION NAY SE GRANTED SY PHS-EHD UPON RECEIPT OF THIS LETT-ER. <br /> DO VCT WR17E IN ANY SNA&D AREAS. <br /> EPA SITE N PROJECT CONTACT L TELEPHONE X <br /> F FAC!LITY NAME <br /> _A , <br /> C ADDRESS (.JO kljk�r . <br /> E <br /> L CROSS STREETW. W*-,( <br /> T OWNER/CPERATCR 1 � <br /> Y 'A kf R A-f 4 ut[7 NONE <br /> C CONTRACTOR NAME KV#,afXWef. . JQA" 1 !FdDt j ?NONE M <br /> N CON"RACTCR ADDRESSik"7 C�P-lcx",x I&A. , 9RYlaiAp C0wvt=V0% LIC NrJpl a•C:l( G CLus k - x mea " <br /> T <br /> R HAZARDOUS 1iASTE CERTIFIED •6S N0 ^ 4RX.Cw.>3 � <br /> A PERMIT 4 <br /> C FIRE DISTRICT <br /> T t , ; <br /> O 644RD OF EG1IALSZATION 8 V' i <br /> R _ - <br /> 111111111I111IIII111111111i11 c / 0 ICALS To t{E srcRED 'PRCPosEO TusT i.LA:ICN <br /> AYiII D A ZIP SSI r Ofd DATE <br /> 34- �� f-s•� _ _ S <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- f <br /> 1111 <br /> 9-39-39- <br /> 1111 <br /> P LAPP777 <br /> ROVED WITH CCNOITTON(5) )CSAPPROVED <br /> ACHMENT WITH CCND(TIONS) <br /> k DuN RE`/IL:kEIIS NAE ✓n✓ =1111 <br /> iili[1111i1111111111 I 1 <br /> DATE <br /> APPLICANT :MUST PI:RFCXM ALL WORK IN ACCCRDAN WITH SAN JOAQUIN CDUNTY ORDINANCES, STATE LAWS, AND ATILES AND REMJLATIONB OF <br /> SAN JCAQUEN CaUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE Cavil mg THE FdLL71ILNG: �[ CERTIFY THAT IN { <br /> THE PERFORMANCE OF THE WORK FOR WHICH TAI PVWIT IS ISSUED, T SHALL NO7 ENP0Y ANY PERSON IN SUCH A FAWNER AS TO 3ECOME ` <br /> SUBJECT TO WORKER'S CC?PENSATIaL LAWS O-�F/ICAL:FCRNIr1." CONTRACTOR'S MIRING OR SLBGDNTRAC'.ING SIGNATURE CERTIFIES THE fULLOIiING:` <br /> "I CERTIFY THAT IN THE P RFORNANCfi OF SIE '.IORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS ZAJECT TO YORKER'S ! <br /> COMPENSATION LAWS OF CAqIfORNI . <br /> fDATE f^" <br /> APPLICANTfS StGNATUR TITLE L J�■"�-�--a"� <br /> i <br /> I <br /> Ind{cat& Lha responsible par :o be iiLcd for additional PNS•EHD staff time axnana�a beyond :he 6 hat' wininAya in6taltat}on <br /> payment. The par-,y wust aduwMiedge this rescnnsibiLity for :he additionai W LLirtg Gy signature and data beiow. <br /> Name INV 1 O <br /> Mai L Ing AdnrasaP �+K C'r q'52-13 <br /> Day Phone N f` -vZ- o 4-6Z q- 7- <br /> r Oat& .G.� <br /> SIgnaturC <br /> R /9;, UT Reg's May EH B 006 S <br /> 4 <br />