INSTALL_1995 TANK TOP UPGRADE - Laserfiche WebLink

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ENVIRONMENTAL HEALTH DIVIStfI iiiiiSeWRIVA FAC. 5569 APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER 1S SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS -END UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. Indicate the responsible party to be bitted for additional PIIS-EIID staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name Tait & Associates Mailing Address IUUI L Day Phone N 510 Signatu Thomw EB Z3 008 (Rev 1/7/92) WP Project Architect 3 Date 5/23/95 EPA SITE # PROJECT CONTACT &TELEPHONE # TaitS&hAssoc CAL 000032494 ateS 1 680-6800 F FACILITY NAME Facilit 5569 PHONE # 20 474-9343 A C ADDRESS 3518 East Hartuner Lane Stockton CA 95210 I L CROSS STREET Holman Road 1 T OWNER/OPERATOR PHONE # Y AROD Products Co. ATTN: Environ. Health & Safet 714 670-5300 C CONTRACT00. NAME American Ronstruction PHONE M 510 447-24 4 D N CONTRACTOR ADDRESS Exchange Ct. CA LIC # CLASS 1 Livermore.9 CA 94064 702214 A T R HAZARDOUS WASTE CERTIFIED YES X NO_ WORK.CCMP.# 571-1486-94 A C FIRE DISTRICT Stockton F.D. PERMIT # - T 0 BOARD OF EQUALIZATION IF TK Ho 44-000506 R I I I 1111111 TANK 111111111111111 TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION 39- DATE T 39- P11¢ffi77� 92 ana ,a O T ne Imm i� A 39- Piping rely 8 n asoma STJDBnes 95 N 39- Pi pt na Only 8.7 Octane Gasoline S Ammer K 39- 39- 39- P 1111 L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A (SEE TTACHM WITH CONDITIONS) N PLAN REVIEWERS NAME 11111111111111111111 DATE 11111 i APPLICANT MUST PERFORM ALL K IN ACCORD ClWI TII SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING! "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: a)� TITLE-ei-R, DATE 5/23/95 Indicate the responsible party to be bitted for additional PIIS-EIID staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name Tait & Associates Mailing Address IUUI L Day Phone N 510 Signatu Thomw EB Z3 008 (Rev 1/7/92) WP Project Architect 3 Date 5/23/95