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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-EHD 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-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE #R1eK- MC'CNuJE Illl-tpM9-�OU3 <br /> F FACILITY NAME 5�V LAIaD -��EV�N PHONE # CIJaW AUTI i - <br /> A <br /> C ADDRESSS ,� 'IZf�N"(14 is �� <br /> 1 <br /> L CROSS STREET <br /> I , <br /> T OWNER/OPERATOR PHONE # <br /> Y C T+11.pw�lJ C6 _ASID - 3—Z111 <br /> C CONTRACTOR NAME PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC # CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES__ NO_ WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> T <br /> Iilllllllllllllllllllllllll <br /> TANNK ID # TANK SIZE CHEMICALS TO BE STORED PRO,PO�ED INSTALLATION <br /> 39- 15000 v.��;. VIJtJ� 'i /I DATE,_ <br /> T 39- TUU L]UiL_D D��i 5.411E <br /> A 39- - �U(700 _ I:�; ,mal. I>n 51,444 CL <br /> N 39- <br /> K 39- <br /> 39- <br /> 11 <br /> 39- <br /> II <br /> II !11 U11 <br /> P OIT <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPP VED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME -�A^//'tee/' ��✓ DATE — <br /> 11 I I i l 1111111 I I I1111� I III 1 1 1 1 1 1 1 III I I I I I I I I I I I I I I I I I I I I I I I I I i1Tll I�I11111 I I I I 1 III I I I I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN 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, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I 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 CALIFSNIA." <br /> APPLICANTS SIGNATURE: TITLE FWC1?'f_ Fi+��(L lf11Av1�DATE-1 1 1 <br /> , <br /> Indicate the responsible party to be billed for a tional PHS-EHD staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this responsib lit for the add itional billing by signature and date below. <br /> mc-c <br /> Name r�1 ,�A/�l4, /7C� `ZI Intl. Yn� <br /> Mailing Address IIL�O �k�7� Ay,6 � � � LU CA <br /> Day Phone Number _W - 4003 <br /> Signature / G Date 1 119 <br /> EH 23 008 (Rev 13/95, UST Regi ) - <br /> 4 <br />