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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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 YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum instattation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. No Maggie McLaughlin / Robert H. Lee & Associates Mailing Address 1137 N. McDowell Petaluma, CA 94954 Day Phone Nug,r 707-765-1660 E EH 23 008 (Rev 1/7/92) WP 3 EPA SITE # CAL 0000 ZL%G'75 PROJECT CONTACT 8 TELEPHONE # Maggie McLaughlin/ R. H.Lee & ASSOC. F FACILITY NAME Chevron U.S.A. PHONE # 707-765-1660 A C ADDRESS 3775 Tracy Blvd. I L CROSS STREET Larch I T OWNER/OPERATOR PHONE # Y C CONTRACTOR NAME PHONE # 0 N CONTRACTOR ADDRESS CA LIC # CLASS T R HAZARDOUS WASTE CERTIFIED YES NO_ WORK.COMP.# A C FIRE DISTRICT City of Tracy PERMIT # T 0 BOARD OF EQUALIZATION # 44-031913 R III111111111111111111111 TANK ID # TANK SIZE TANK CHEMICALS TO BE STORED PROPOSED INSTALLATION 39- DATE T 39- 12.000 gal _ _ su reme unleaded T� A 39- X000 gal us un eaded �gj N 39- 12.000 gal _p reg. unleaded 1995 K 39- 39- 39- III1111 1111111111111111111111 Illiililiilllllillllllllllliliii IIIIIIIIIIIIIIIIIIII1111111111111111111 IIIIIIIIIilllllilllll P L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A (SIATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME Y o / i �i G<--- 11 111111111111111111 y L,...�.2� DATE '..L • — C` fIT1 IITTTTI I l I i l 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 AGENT'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: "I 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." APPLICANT'S SIGNATURE: Y�C�.� /- - LEE TITLE t,1613/ 4O%3 07)9, L-_ DATE 7 IO JC A -Ss x Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum instattation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. No Maggie McLaughlin / Robert H. Lee & Associates Mailing Address 1137 N. McDowell Petaluma, CA 94954 Day Phone Nug,r 707-765-1660 E EH 23 008 (Rev 1/7/92) WP 3