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0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES COPY ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. 00 NOT WRITE IN ANY SHADED AREAS. Indicate the responsible party to be bitted for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The party mut acknowledge this responsibility for the additional billing by signature and date below. Name C�2�� 111 C� t -. --f �L 1 /'Oa G C,70r .�4 �n Mai l ing Address /Z(�1 C, T& S 7- P'.1 C-A9t-7(p(- Day Phone Number L19- L Z C- 3 7 Z'1 L)-.. If, Si EH Date/11'a� ( I �- EPA SITE # CAL C000 -n 04 1 PROJECT CONTACT 8 TELEPHONE #Aj L)t d. Q - 1 I Q 15 rz-3 Lf Z F FACILITY NAME (,l j* �J PHONE # A L Ni C I ADDRESS o L 1 CROSS STREET T OWNER/OPERATOR A 60"A Hitt (A. PHONE # Y G(SA FAS (DGIA36 CO)P- 3e�lol A cuo ct, 1 81 LS- "g( -S - Lr C 0 CONTRACTOR NAME Own1E�_ PHONE # Oq_ 2.7x3 qv -ea -11S N CONTRACTOR ADDRESSIZ I - 7(„ _ CA LIC # QyIAJk CLASS T .�.. Q bl� R A HAZARDOUS WASTE CERTIFIED YES_ NO_ WORK.COMP.# .SEiF5 C FIRE DISTRICT PERMIT # T 0 R l� BOARD OF EQUALIZATION # ly _ 0-3 37(0 111111111111111111111111111111 TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION 39- i&dftft--z 000 _fid Sol, 'ATE�� A 39- eo A, o ,-, N 39- ra K 39- 39- 39- P 1111 �111T111TfinTTI1Tijjj� L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED _ A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE IIIIIIIIIIIIIillllll II II IIIIIIIIIIIIIII I liiiiiiiiiiiiiiiiiiiiilillifillilliffilI111111 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED A(;ENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." 11�� I APPLICANT'S SIGNATURE: ' TITLE 1�('O�ect-' 000n41)4TE S S Indicate the responsible party to be bitted for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The party mut acknowledge this responsibility for the additional billing by signature and date below. Name C�2�� 111 C� t -. --f �L 1 /'Oa G C,70r .�4 �n Mai l ing Address /Z(�1 C, T& S 7- P'.1 C-A9t-7(p(- Day Phone Number L19- L Z C- 3 7 Z'1 L)-.. If, Si EH Date/11'a� ( I �-