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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <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 ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS'LETTER.. •__. _ <br /> DO NOT WRITE IN ANY SHADED AREAS. A <br /> EPA SITE # PROJECT CONTACT d TELEPHONE # bill &)er�er- 0 10 555- 710 1T <br /> F FACILITY NAME Circle k F26i i iix # IZp PHONE # <br /> A <br /> ADDRESS ICA70 /�Gdmer; c La�hro <br /> L CROSS STREET <br /> I L- 5e- Ave <br /> - <br /> T <br /> V <br /> T OWNER/OPERATORPHONE # <br /> Y J105G0 nsrkdiw)c ( , 7&1Z <br /> C CONTRACTOR NAME .-.1L1; {ie. rOleU�� PHONE # <br /> 0 !�P <br /> N CONTRACTOR ADDRESS (Y A�F�Jc� h� a j CA LIC # �LD`..-'7c CLASS <br /> T A �� GHQ <br /> II <br /> R HAZARDOUS WASTE CERTIFIED YES ' _ Na— WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT 9 <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> 1111111111 <br /> TANK 11111111111111 <br /> TANK ID # TANK 512E CHEMICALS TO BE STORED PROPOSED INSTALLATION .. <br /> 39- DATE <br /> T 39- <br /> A 39- <br /> N 39. <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( TF11 TACeHMENT WITH CONDITIONS) fi <br /> H PLAN REVIEWERS NAME �I.�IU`_ DATE Aan <br /> IIIIIIIII11111111111 �T I 111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." -t� 1. <br /> APPLICANT'S SIGNATURE: (-1 L. Dt5 ' 60' TITLE 6a^.t {ir YW I-I Mh DATE � JZ <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minis installation <br /> Payment. The party boat acknowledge this responsibility for the additional billing by signature and date below. <br /> Hame 2 a LJ1Dlino Prod�� �nnrGlin�{vr <br /> Mailing Address I��I� W//�IIo� P//a2ss IZa^oci'S" Lic a - IZe7 Lori Jd GA g4j2w <br /> Day Phone Hurber 510 _ &CA�. `2-30n .. _,... . <br /> Signature_ �iT.��.[rc^��—i Date <br /> EH 23 008 ev2/,13/95CAT Reg's May 5, 1996) <br /> 4 <br />