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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS 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 TIME, ONE YEAR 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 -END staff time expended beyond the o nour minimum instauacnw.. <br />payment. The party must acknowledge this responsibiLity for the additional billing by signature and date below. <br />Name ljr li o -1'6b�-C� c.a ..t-- C-0-' a C , {n�-� 4 - <br />Hailing Address IZLo I E qMa v y v&A-QA A A "�� <br />Day Phone Lumber -1 U:_ Vd L L - <br />Signature A- ' <br />EH 23 006 (Rev 12/13/95, UST <br />UST SYSTEM DRAWING INFORMATION <br />a <br />Date, 12-75- ! 7 <br />EPA SITE # 0000 <br />PROJECT CONTACT & TELEPHONE # <br />90Q - _ <br />IgnL <br />F <br />FACILITY NAME USA <br />PHONE # <br />A <br />C <br />ADDRESS-ZST <br />a <br />I <br />L <br />CROSS STREET CLl 4 L- <br />I <br />T <br />OWNER/OPERATOR LA5A ` G <br />'ASO <br />PHONE # <br />Y <br />30101 A f -r. +'1" A o Hi lir, <br />S(oS-9 zoo <br />C <br />CONTRACTOR NAME USA Olw1AL.% tA. A <br />PHONE 11 90q- 622- L <br />0 <br />N <br />CONTRACTOR ADDRESS ' Z(p QtL C MY N� <br />CA LIL # <br />CLASS <br />T <br />R <br />HAZARDOUS WASTE CERTIFIED YES_ NO_ <br />WORK.COMP.# <br />A <br />C <br />FIRE DISTRICT <br />FLOIA,• <br />PERMIT # <br />C ,�jr f <br />T <br />0 <br />BOARD OF EQUALIZATION y y „ 0-53 <br />R <br />IIIIh&#IIIIIIIIIIIilllllll <br />TANK ID TANK SIZE CHEMICALS TO BE <br />STORED PROPOSED INSTALLATION39- <br />(oo IW 1. <br />DATE/91 <br />T <br />39- <br />�D'Oo0 <br />LAUL r <br />A- <br />39- <br />12 oo0 i D <br />(ANL re <br />N <br />39• <br />Sp. L—�T nOD <br />LL4 t�1 <br />K <br />39- <br />39- <br />IIII III 1111111 III I IIII II11 1 111111111 <br />iillill111 111111IIII II11IIfI <br />L <br />L <br />APPROVED APPROVED WITH CONDITION(S) <br />—DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />I I I I I[ I I I 1111 I I 11111 <br />I I III 1T1 ITIITIITII <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE <br />LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES <br />THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY <br />PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />TITLE 17 D %DIG <br />v <br />7A(QMVJI TE 7S -r, ' <br />APPLICANT'S <br />SIGNATURE: <br />indicate the responsible party to be billed for additional PHS -END staff time expended beyond the o nour minimum instauacnw.. <br />payment. The party must acknowledge this responsibiLity for the additional billing by signature and date below. <br />Name ljr li o -1'6b�-C� c.a ..t-- C-0-' a C , {n�-� 4 - <br />Hailing Address IZLo I E qMa v y v&A-QA A A "�� <br />Day Phone Lumber -1 U:_ Vd L L - <br />Signature A- ' <br />EH 23 006 (Rev 12/13/95, UST <br />UST SYSTEM DRAWING INFORMATION <br />a <br />Date, 12-75- ! 7 <br />