Laserfiche WebLink
11-33-7999 2:SBPM FROM F _ a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> TXE APPLICATION FOR INSTALLATION Of L04004IRMNO STORAGE TANKS IS CNLY VALID FOR THE CALENDAR YEAR IN WHICH :T HAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO TIRE NEXT CALENDAR YEAH 10 A LETTER IS SENT TO PHILSHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR TEM. A ONE TIME, ONE YEAR E)RENSION MAY K CRANTM SY PNS-EMO UPON RECEIPT OF THIS LETTER, <br /> 00 NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE Y PROJECT CCN'rACT & TELEPHONE M <br /> CA�OWU32'l9y f /m1 P �9� <br /> F I FACILITY NAME <br /> C 1 ADDRESS <br /> ' 3 <br /> CROSS STREET <br /> 4r i <br /> i <br /> C CONTRACTOR NAMEI PHONE a ,CA/�' <br /> O Qy n <br /> 1 N CONTRACTOR ADDRESS CA LIC X /Cl/ CLASS /./, N/♦ <br /> T ' YYY <br /> a. <br /> R HAZARDOUS WASTE CERTIFIED TES _ NO_ "K-camF.2A3712 -97 <br /> IA G <br /> FIRES DISTRICPERMIT s i <br /> O EOARD OF EQUALIZA710M 3 <br /> R <br /> uuulw <br /> ANK inmlllul 1 <br /> ' TAMK i TANK SIZE I CHFMYly1L5 TO EE aTCRF7 iXtOPCSEO [NSTALLAT[04 <br /> j 39- •—J DATE <br /> 14 39• ' <br /> 4 39- .�..—..I <br /> I K 39- <br /> 39- <br /> P <br /> 9-39-o / X <br /> OVED Wl7N t0l0IT IONS) OSSAPFROVEO <br /> 'A /(�� ,,J/%(SE I JIM CCNOITIONS) <br /> N PLAN REVIEWERS NAME [�..[�/i� %•''�� %-4'I oATE <br /> nnnnnuwlun l u II II w �i�►liTRi��itlf�mmmTllmmiTiTiutu� u � su I I I ut I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH $AN JOAQUIN =ATY CROINANCES, STATE LAYS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN CMNTY PUS-0C HEALTH SERVICES. OWNER OR LICIMSN AMT'S SIGNATURE CERTviss THE FOLLOWING: *1 CERTIF`- THAT IN <br /> TME PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SLICK A MANNER AS TO SECOME <br /> IW&JECT TO WORKER'S COMPINSATIOA LAYS Of CALIPORNIA." CCNTRACTOR'S HIRING OR SIMCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:i <br /> "I CERTIFY THAT IN THE PERFOR. CE CP TME. WORK FOR WNICi THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS s H.ECT TU WURRER'S <br /> OONPEN&ATION LAWS OF CALIFOR ,{/ <br /> APPLICANT'S SIGNATURE: TITLE n /, CATF -J <br /> !ndicate the respamibte party -a be ci LLed °ar citicnal PNS-EMO staff Lime exoen9.0 beywid the 8 hour sini. ira:tallat:on <br /> Cayment- The par Roast ac lecpe his responsibility for the adaicional bil " by Sigwur u•e and date below. <br /> Nam 1p�lone• <br /> Maitin9 Aduress 42aw �GNVIC.,ISL '" lS <br /> Day P"lone 4Wmber <br /> ilBnetWl'e ono- <br /> 14 Z3 008 (Rev 13/95, UST ReS'S MDY t ) <br />