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..41 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK*INSTALLATION PERMIT ` <br />Cil; New turbine SUmp ,rank yalke , oderFill prev•& c' i5P. ('onS <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 -END 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 -ENO UPON RECEIPT OF THIS LETTER - <br />DO NOT WRITE IN ANY SHADED AREAS. <br />...,�a.< <"< rasponsibie party to be billed for additional PHS -END staff time expended beyond the 8 hour minimum instaLlation <br />payment. The party must acknowledge this responsibi Lity for the additional billing by signature and date betow. <br />Name FLU L Cx=,ian Lprcu e l n6- r7 ( 2Nn . Z2ig2 2n Ino) <br />Mailing Address 1510 Willow Pbr Vzod V 5orkko -� C,oncor4 ; GA 0145 <br />Day Phone <br />EPA SITE # <br />PROJECT CONTACT 8 TELEPHONE # <br />S/E' ('Vin, (gIG)558-7007 <br />AFACILITY <br />NAME do I I HCl l l <br />OirM) <br />PHONE # ('zL->l) -'ci1&4 -oiiq <br />C�l <br />C <br />ADDRESS <br />EH Z3 008 <br />1 <br />(/!o <br />Reg's May 5, 1994) <br />L <br />CROSS STREET ar t h <br />T <br />Y <br />OWNER/OPERATOR <br />TOS <br />PRONE <br />55g -7&12- <br />C <br />0 <br />I CONTRACTOR NAME Walter iyleeei /Gon�trucilo n <br />HONE # <br />0 16,)372 - IS$i3 <br />TCONTRACTOR <br />ADDRESS QA lzi.T.,. Laie 1 1• tom,, ,.ate y__ <br />7F� W /"—u rW0 <br />CA LIC # -017235 <br />CLASS A 15j Nae <br />R <br />HAZARDOUS WASTE CERTIFIED TES CK NO <br />WORK.COMP.#WNGI�rj I -7 <br />A <br />O2 <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />BOARD OF EOUALIZATION # <br />R <br />111111111111111111111111111111 <br />TANK ID # TANK S C LS TO BE STORED PROPOSED INSTALLATIONI <br />39 <br />DATE <br />T <br />39 - <br />A <br />39- <br />N <br />39- <br />K <br />39 - <br />41 <br />39- <br />39- <br />I I I I I1Tii1IT�111f <br />I <br />P <br />L <br />APPROV D WITH CONDITION(S) <br />DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />DATE <br />111111111111111111111 1111111111111111 1111 11111111111 111111 <br />I II 111111111 111 I 1 11111111 1 <br />APPLICANT MUST PERFORM ALL WORKNCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />SAN JOAQUIN COUNTY PUBLIC HEALTOWNER <br />f <br />STATE LAWS, AND RULES AND REGULATIONS OF <br />OR LICENSED AGENT'S SIGNATURE <br />THE PERFORMANCE OF THE WORK FOR PERMIT IS ISSUED, I SMALL NOT EMPLOY <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATIOALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFORMAWORK FOR WHICH THIS PERMIT IS ISSUED, <br />COMPENSATION LAWS OF CALIFORNIAA�""-fAPPLICANT'S <br />I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />SIGNATURE:L d TITLE <br />Aaanr � LO566 DATE 12Al-All <br />...,�a.< <"< rasponsibie party to be billed for additional PHS -END staff time expended beyond the 8 hour minimum instaLlation <br />payment. The party must acknowledge this responsibi Lity for the additional billing by signature and date betow. <br />Name FLU L Cx=,ian Lprcu e l n6- r7 ( 2Nn . Z2ig2 2n Ino) <br />Mailing Address 1510 Willow Pbr Vzod V 5orkko -� C,oncor4 ; GA 0145 <br />Day Phone <br />Number �rJ�a) <br />'i0 .7 OD <br />Signature <br />OirM) <br />//(L7'0q <br />C9.MiK+�� <br />IZ/3��� <br />EH Z3 008 <br />(K XZ/1�/95,,#C <br />Reg's May 5, 1994) <br />Date <br />