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ENVIRONMENTAL HEALTH DIVISION APPUCATION FOR UNDERGROUND TANK INSTALLATION PERMIT APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT RAS BEEN ISSUED. A PERMIT MI1Y BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PNS -END REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE ENO OF THE CALENDAR TEAR. A RE YFAR -- RE TIME EXTENSION NAT E GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. DD NOT WRITE IN ANY SHADED AREAS. EPA SITE #CAI FACILITY NAME ADDRESS CROSS STREET OWNER/OPERATOR CONTRACTOR NAME HENS t CONTRACTOR ADDRESSz RAZARDWS WASTE CERTIFIED FIRE DISTRICT y BOARD OF EQUALIZATION # III 1 TANK1 I 011�1I111111111 39- 39- 39- 39- 39- 39- 39 - III P L A N PLAN REVIS PROJECT CONTACT d TELEPHONE # 7 YES -L, NDS APPROVED G LIC # PNORE # PHONE # -PHONE YI2o 3- CUSS PERMIT # SIZE ()� CHEMICALS TO BE STORED �l APPROVED WITH CONDITION(S) _ DISAPPROVED ;K ATTACHMENT WITH CONDITIONS) DATE G SCJ 1111111 INSTALLAT If 111111111111111EWER11111921.441................ APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAWIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF TCTING �N"I CERTIFY T IN NTHLIEfHSCIOWNER OR AGENT'S SIGNATURE CERTIFIES THE JOAQUIN COU LIFORNI.SSUED ISHALLNOTEMPLOY ANY PERSON IN SUCH AMANNERA0BECOME E PERFORMANCE THE WORK PIT I SBJECT TO -1 CERTIFY TI�HATE INS THEM PERFORMANCE OF THECA FORA RAWHICHH THIS CPERMIT TORIS H IS ISSUED, ,IIWSNHALL EMPLOY I PERSONS SUBJECT ETOTHWORKERI•SWING: COMPENSATION LAWS OF CALIFORNIA." TITLE �11- b \EL. I DATE APPLICANT'S SIGNATURE- Indicate the responsible party to be billed for additional PNS-EHD staff time expended beyond the 8 hour minima installation Payment - The party must acknowledge this responsibility for the additional billing by;ignatureG date below. �� ,t 5 Name UC.2 Maiting Address 2. D� 5 4L Day Phone Nmbe Signature EH 23 008 (Rev 1/7/92) WP R