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ENVIRONMENTAL HEALTH DIVISION <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 TINE 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 b TELEPHONE# <br /> F FACILITY NAME PHONE # <br /> A <br /> G ADDRESS <br /> I <br /> L CROSS STREET <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> C CONTRACTOR NAMEPHONE #" ADVANCED Environmental Services, Inc. ��� 928-8300 <br /> a <br /> N CONTRACTOR ADDRESS 1419 N. Market Blvd. , Ste.5,, "Sact .CA LIC # 695787 CLASS A—HAZ Cert. <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES X NO WORK.COMP.# NWC-274486-00 <br /> A PERMIT # <br /> C FIRE DISTRICT City of Stockton. <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> II[[[Ii1111111i1l1111!l11ltt[t " <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39= 12,000 Petroleum 7 99 DATE <br /> T 39- a ro earn <br /> A 39- a ro eum7/95 <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9- <br /> 39- <br /> 39- <br /> . <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A iSEE•ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> lIllllillllllllI{{lI l I I I I 11 1 IIIIII ! "! IIII llllllll <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: . "I CERTIFY THATIN <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-CALIFORNIA." - <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> Indicate the responsible darty to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum instaLLation payment. <br /> The party must acknowledge this responsibility for the additional biLLing by signature and date below. <br /> N arae <br /> Mailing Address <br /> Day Phone Number <br /> Signature Date <br /> EH 23 008 (Rev 1/7/92) WP <br /> 3 <br />