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• <br />ENVIRONMENTAL HEALTH DIVISION <br />F--1 <br />A <br />APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br />APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. <br />A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS -END REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHO UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />Indicate the responsible Party to be billed for additional PHS-EHO staff time expended beyond the 8 hour minimun installation Payment. <br />The party must acknowledge this responsibility for the addit9wal billing by signature and date below. <br />Nage California Petroleum Equipment Inc. <br />Hailing Address PO Box 9364 Fresno Ca. 93792 <br />Day Phone Runber 209-276-1881 Fax 209-276-1894 <br />EH 23 008 (Rev 1/7/92) WP <br />Date 09-28-95 <br />0 0 <br />EPA SITE R <br />PROJECT CONTACT & TELEPHONER 707-746-6691 John Johnson <br />F <br />FACILITY MANE Super Cheaper #104PHONE <br />R Unknown <br />A <br />C <br />ADDRESS SW. Corner of Lathrop rd. & Cambridge Dr. <br />L <br />1 <br />CROSS STREET <br />T <br />T <br />(AER/OPERATOR <br />The Customer Co. PO Box 886 Benicia Ca. 94510 <br />PHONE R <br />707-745-6691 <br />C <br />CONTRACTOR NAME Calif. Petroleum Equipment Inc. <br />PHONE R 209-276-1881 <br />0 <br />N <br />T <br />CONTRACTOR ADDRESS PO Box 9364 Fresno Ca. 93792 <br />CA LIC R 432613 <br />CLASS A, B. C61 -D40 <br />R <br />A <br />HAZARDOUS WASTE CERTIFIED TES X NO_ WoRK.CONP.R 1048003-94 <br />C <br />FIRE DISTRICT PERMIT N <br />T <br />D <br />R <br />BOARD OF EQuaLlzArlox R The Customer Co. Under round Storage Tank e # TYHQ44-018591 <br />11IIIIIIIIIIfttlllllllllll <br />1 <br />TANK [D R TANK 512E CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- 20.000 Qal Unlead Gasoline 11-95ATE <br />T <br />39- <br />20.000 cal <br />Premium unlead Gasoline11-9 <br />A <br />39- <br />20.000 qal <br />Supreme unlead Gasoline <br />11-95 <br />N <br />39- <br />_ 12.000 pal_ <br />Wai <br />1 <br />K <br />39- <br />550 aa1 <br />_ t011 <br />j_9— <br />39- <br />39- <br />Mill 1 1 I I III I 11 1 <br />P <br />L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />_ <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />Illlllllllllltllllll 11111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN 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, 1 SHALL 40T EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S MIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALI{F'CRRNNII,A�." <br />APPLICANT'S SIGNATURE: J �/�'ryC./ //�GC.G(-lY1A/ TITLE Contractor DATE 09-28-95 <br />Bryce uschhau t President of alif. Petroleum Equipment Inc. <br />Indicate the responsible Party to be billed for additional PHS-EHO staff time expended beyond the 8 hour minimun installation Payment. <br />The party must acknowledge this responsibility for the addit9wal billing by signature and date below. <br />Nage California Petroleum Equipment Inc. <br />Hailing Address PO Box 9364 Fresno Ca. 93792 <br />Day Phone Runber 209-276-1881 Fax 209-276-1894 <br />EH 23 008 (Rev 1/7/92) WP <br />Date 09-28-95 <br />0 0 <br />