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• i <br /> 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 RHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> 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. <br /> DO NOT WRITE 1N ANY SHADED AREAS. <br /> EPA SITE # C AY)4)8, 1-4,5 q-Aq PROJECT CONTACT $ TELEPHONE # ` 1() 3-3 <br /> F FACILITY NAME � ll�, PHONE if — <br /> A �l <br /> C ADDRESS w7I <br /> 0, n]A-i ig <br /> ?�(p <br /> I <br /> L CROSS STREET i A-,v <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y Z L Cir IS Cad 7�— <br /> C CONTRACTOR NAME n 1/�p'� -pjCjq� �� x"�') j PHONE # <br /> 0 1� <br /> N CONTRACTOR ADDRESS CA LIC # CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES_- NO WORK.0014P.# <br /> A <br /> C FIRE DISTRICT C � PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R. <br /> IIIlIIIIII11111I111111111111II <br /> TANK ID # TANK SIZE CHEMICALS TOB STORED PROPOSED INSTALLATION <br /> 39- /S..Pl<? fri i DATE <br /> T 39- ax.5 f[2�71� �� t.l� r [l+✓. I e% S <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> III <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A �—EE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME <br /> IIlIluIIIIIIIIIInI I I 1Diiil <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 AG'ENT'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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> r/ n •` <br /> APPLICANT'S SIGNATURE: TITLJ DATE <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the B hour minimum installation payment. <br /> The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name ` <br /> Mailing Address -qts— I L (ILK V ITL- 39-1,)�l alc�L <br /> Day Phone Numberr©'1 1 Sri <br /> Signature Date <br /> EH 23 008 (Rev 1/7/92) WP <br /> Sr i A +ACJ-lr--rd &C 0 F- L 0-4-+ea, �.1oaE,+nb�r� ,a 199 <br />