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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 HE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />1� 7 DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE # <br />PROJECT CONTACT b TELEPHONE <br />F FACILEfY NAME L,F� SVc <br />A <br />PHONE # Z-03�5-�3 <br />I (� <br />ADDRESS ( z� � � 1 VA 1E LO UA" <br />L CROSS STREET �'� �� 9 -7>f <br />I <br />T OWNER/OPERATOR <br />YL Lm r2 a ti z � L C �F. .� a—<�OV)Ls V-, < <br />PHONE # <br />40 <br />C CONTRACTOR NAME N T��rpS <br />0 <br />PHONE <br />i <br />"CONTRACTOR ADDRESS �vZ,�r� F�t �,j�CA LIC # <br />T y `w <br />CLASS <br />R HAZARDOUS WASTE CERTIFIED YES NO <br />WORK.COMP.# C(� - <br />--y— <br />A <br />` A _r q <br />C FIRE DISTRICT C ��, cL-0 Q"\ <br />PERMIT 0 <br />T <br />O BOARD OF EOUALIZATIDH # `a�bAA� 9�—�Q4OA <br />-- <br />R <br />t���tt����tttt��ttt������t���� <br />TANK D # TANK SIZE CHEMICALS 'NOW STORED INSTALLATION <br />ZA <br />39 DATE <br />T 39- <br />A 39- <br />N 39 to Z-00 Cl +tt Rh g <br />K 39- 13CDAA 0 t -$ ' <br />39- <br />39- <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE g <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 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />�jJ( <br />APPLICANT'S SIGNATURE: TITLE �� �H DATE 111 <br />Indicate the responsible party to be billed for additional PHS -EMD staff time expended beyond the 8 hour minimum Installation <br />payment. The <br />party <br />�/must a knowledge this responsibility for the additional billing by signature and date below. <br />Name t 1' . t�`�}Y <br />Mailing Address.Q� <br />Day Phone Number <br />Signature <br />EH 23 008 (Rev 12/ <br />, UST Reg's May 5, 1994) <br />UST SYSTEM DRAWING INFORMATION <br />4 <br />Date 4 1—s' <br />