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ENVIFIONmENTAL NEAL7N DIVISION <br /> 30' Weber Ave.Third Floor <br /> P.O.Bo,,,r68, SbCMM,CA 95201-0388 <br /> Phone: (209)468-3420 <br /> ENVIRONMENTAL HEFbT}i D(IVIISSION <br /> APPLICATION FOR UNDERGROUND 'Rp'ffR1f/�IL e?mii'llt<irnaft <br /> 1u Ukapproved: See Fter> <br /> APPERMITION MAYFOR E%TENDEDTINO TNEOF NNE%TRGLENDARKYEARE IFMLY VALID FA LETTER IS� LENDAR YEAR IN VHIC TENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME E%TENU0k' wey A GRANTED_ BY PNS-END ER. <br /> DO NOT WRITE IN ANY SHADTFFIFEAS:-�"""^----- .-------- � <br /> EPA SITE # CAD S q aI - PROJECT CONTACT 8 TELEPHONE <br /> F FACILITY NAME `_ !� iceprOVa O th <br /> A OL< J r ►eon but <br /> I ADDRESS _lel I --M A Na. does not aU <br /> r t n of <br /> L CROSS STREET © '� requirements Ot State <br /> I <br /> T OWNER/OPERATOR GME # <br /> Y 4-�>He-IL- ©tom CoM - 6 i - bi4J <br /> C CONTRACTOR NAM T.. _ PHONE / l 2 <br /> 0 <br /> N CONTRACTOR ADDRESS — LIC # -x)Z -4 CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES No WORK.COMP. <br /> A <br /> C FIRE DISTRICT C I b� S PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION <br /> R <br /> 1111111111 <br /> TANK 111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- Js - - VA.) DATE <br /> A 39- <br /> M 39- <br /> K 39- <br /> 39- <br /> 39- <br /> IIII <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (S ATTR NT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> IIIIIIIillllllllllll111111 I I <br /> APPLICANT MUST PERFORM ALL IN 1AIC11ZAN 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, i 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, I SHI EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> i <br /> APPLICANT'S SIGNATURE: TITLE / �- DATE <br /> Indicate the responsible party to be biLled for additional PHS-EHD staff tim expended beyond the 8 hour minirmAn installation payment. <br /> The party mist acknowledge this responsibility for the additional billing by signature and date below. <br /> Name Ppr!�> �tr— <br /> Mailing Address `ham Q yt� lll, � SVLTr;: � r )QLlJJ1�—CCjzj�zt Cla � <br /> Day Phone Hunber .- <br /> Signature Date 12 <br /> EH 23 008 (Rev 1/7/92) WP <br /> w\l pf lO�r 7� InS�Ca.LLO�[O� <br /> v 3 I // <br /> 20 Lwteu cJe1�"( � o .sem Plate 4c� 6 L r .L4",j- 40 <br />