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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br />TME APEL:CATICN FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR TEAK IN WWI IT IT NAS a IMF PERMIT MAY BE EXTENDED INTO THE NEXT CAL`�WOAR YEAR IF A L-°TTER IS SENT 70 PNS-r](D REWESTf NG TRIS EXTENSION THIRTY RATS <br />PRIOR f0 THE END OF THE CALEHOAR TEAR. A ONE TINE, ONE YEAR EXTEINSION MAY SE GRANTED ST PHS -140 UPON RECEIPT OF THIS LITTV. <br />DO NOT WRITE IN ANY SHADED AREM <br />I .PA SITE S I PROJECT CONTACT d TEL" a <br />� AIS 6Jv6(NN5ERIN6 !91194?- 364¢ <br />F FA":TT NAME 3EACON #3x7�o ' PHONE x20 7 7Yyt• <br />A 4 27 <br />C i ADDRESS i 131-15 6. HIGpWAY U LOcKEFDAD. <br />L I CROSS STREET �NERRy ST. <br />I' <br />T I OWER/OPERATOR <br />I PHONE 9 <br />r ' V'4TRAMA9 /NC. 5759 583 3235 <br />C CONTRACTOR NAME <br />0 ` aHONE s <br />N I CONTRACTOR ADDRESS I <br />:A Lfc Y <br />T '� CLASS <br />R :HAZARDOUS WASTE CERTIFIED YES_ ND <br />I WORX.C�,P.s <br />A ' <br />T FIRE DISTRICT I a„a1t1 t <br />0 I $CARD OF EQUALIZATION If <br />R i <br />� <br />i <br />�ftI111fI1111ii111IIHil11lIIU � -- <br />zzEE <br />39- 5(1-1 EX/SNX N6 1 cmeccALs rD BE vmEn PRr�ostNsraLrLrtoN <br />r'� <br />T <br />f <br />39• _ _GA Sbu.vg DATE <br />--T— <br />A <br />39- 5 - �xtSTt/— <br />� <br />y' <br />N <br />i9• <br />r , <br />i <br />I <br />39- <br />39- <br />1111 <br />IP MTM TTffrr 1117 <br />iL ROVED <br />A APPROVED VITA C•-WDIT:CN(S) OISAPPROWE7 <br />ATT T WITH =WITtGNSt <br />N PIAN REVIE'JERS NAME �^--r[ljit.` {+T <br />Ar <br />11111!!!1!)lIIIIIIII llil <br />111 lfi 111 U II lllllllllf Ili !11111 1 II <br />APPLICANT MUST PERFCRM ALL LORK IN ACCORDANCE WITH SAN JOAQUIN CAINTT CaDIMAN(ES, STATE LAYS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTT PUBLIC HEALTH SEKv ICS$- OWNER OR LICEMO AGENT'S SIGNATURE CERTIFIES THE FCLLCUf "I <br />C: CERTIFY TWAT :N <br />ANE PERFORMANCE OF THE WORX FOR '."ICH THIS PERMIT IS ISSUED, 1 SHALL 440T E.ftOT ANY PE31Si9 IN SUCH A MAANER AS TO BECOME <br />I <br />SUBJECT TO WORKER'S CaWCNSATIOM LAWS OF CALIFORNIA.- CONTRACTOR'S 41RIXG OR SU8=TRAGI4G SIGNATURE CERTTFi ES THE F,LLCWrNa <br />CARTIFY THAT fN THE PERFORMANCE OF THE WCRK FOR WHICH TRIS PERMIT :S ISSUED, T SMALL EMPLOY PSRSCRS SUBJECT TO WO(IZR'S <br />MIPSNSATION LAYS OF CALIFORNIA.- <br />APPLICANT'S SIGNATURE: •'E'er'/ TITLE PRoJ. MGR. oATe 10 <br />I <br />•• wnw.,.. arty co a aN IINp tar am,tiana, PNS -,ND s:af? .fine expendsd b'eYEnd the 8 hP r mininxxn irtstsllation <br />?aYAent. The Garry muni ackJNM,ledp Chia reKNellsi6ility 'er yte Amitlenal 'bitting b1' slgngtt - and lite below. <br />HanN: \)L.T RAMA(l INC. <br />Hailing Adcress 525 W. THIRD ST. HANFORD eA 13230 <br />DAY Pnbne loser X59 583 32 35 <br />IH 13 008 (Re• 12/73/9$, UST Reg'S May 51 <br />3 <br />et'd rHa,��-raar^T , <br />