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EPIRONMENTAL HEALTH DIVISION • <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UMDERGRCUNO TANKS ARE ONLT 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 OATS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION NAT BE GRANTED BY PHS-ENO UPON RECEIPT OF THIS LETTER. ' <br /> 00 NOT MITE IN ANY SHADED ARDS. <br /> EPA SITE 0 PROJECT CONTACT i TELEPHONE 1 707-746-6691 John Johnson <br /> F FACILITY .NAME Super Cheaper#104 PHONE M Unknown <br /> A <br /> C ADDRESS SW. Corner of Lathrop rd. & Cambridge Dr. <br /> L CROSS STREET <br /> T OWNER/CPERATOR PHONE <br /> Y The Customer Co. PO Box 886 Benicia Ca. 94510 707-745-66911 <br /> C CONTRACTOR MANE Calif. Petroleum Equipment Inc. PSE s 209-276-1881 <br /> 0 <br /> N CONTRACTOR ADDRESS PO Box 9364 Fresno Ca. 93792 CA LAC M 432613 MA.ss A, B. C61-D40 <br /> OIS <br /> r <br /> R HAZARDOUS WASTE CERTIFIED TES X xo_ WORK.LOIP.4 1048003-94 <br /> A <br /> C FIRE OISTR ICT PERMIT R <br /> 0 BOARD OF EQUALIZATION M The Customer Co. Underground Storage Tank Free# TYHQ44-018591 <br /> t <br /> I1111111111Al LAANKNK 1I0 D TAYC SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- 20,000 gal Unlead Gasoline 11-99ATE <br /> T 39- 20 000 aal PremlUm unlead Gasoline 11-95 <br /> A 39- 20,000 Dal Supreme anlead Gasoline 11-95 <br /> a 39- 19 000 pal DiesnM 11-95 <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39- <br /> 39- <br /> P <br /> L _ APPROVEDAPPROVE➢ WITR COWITION(S) _ DISAPPROVED <br /> A ( ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS MAX DATE <br /> IIIIIII11111IfIII III fffulmil fif 1111til 111111111 if fill if I 11111111111111111111111 IlnT=11111 IIIIIIIIIIIIIII <br /> APPLICANT MUST PERFORM ALL WOO( IN ACCORDANCE WITH SAM JGAOUIM COUNTY ORDINANCES, STATE LAWS, AND RULES AND REOJLJATIONS OF <br /> SAN :OAQUIN COLINTY PUBLIC HEALTH SERVICES. OWER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: el CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSN®, I SHALL NOT EMPLOY ANY PERSON IN SUCH A HAMMER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION GWS Of CALIFORNIA.- CONTRACTOR'S MIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> •1 CERTIFY THAT IN THE PERFORKaNCE OF THE WORK FOR WHICH THIS PERMIT IS ISM, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALI4ce <br /> FORMIIA.• <br /> APPLICANT'S SIGNATURE: l //�_ TITLE Contractor DATE 09-28-95 <br /> schhau t President of alit. Petroleum Equipment Inc. <br /> Indicate the responsible parry to be billed for additioot PNS-EHO staff tine expanded beyond the 8 hour minima installation paNant. <br /> The party ant acknatedge this responsibility for the additional billing by signature and date below. <br /> a.na California Petroleum Equipment Inc. <br /> Mailing Address PO Box 9364 Fresno Ca. 93792 <br /> Day Phone Naber 209-276-1881 Fax 209-276-1894 <br /> Signature Date 09-28-95 <br /> Bryce Ruschhaupt <br /> EH 23 OC8 (Rev 1/7/92) WP <br /> SF—rJS' b' <br /> ��L),d� �Na-a s4- <br />