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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 PNS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # CAT)982340879 PROJECT CONTACT & TELEPHONE # Mike E1iason , ( 209) 948-9412 <br /> F FACILITY NAME Woolsey Oil Cardlock PHONE # ( 209) 948-9412 <br /> A <br /> C ADDRESS 930 East Victor Road , Lodi , CA 95240 <br /> I <br /> L CROSS STREET Between Beckman and Cluff (Just East of 99) <br /> 1 PHONE it <br /> T OWNER/OPERATOR Woolsey Oil , Inc ( 209) 948-9412 <br /> Y <br /> PHONE 5 3 0) 878-6834 <br /> vJ1130n 12trGi2llm Construction <br /> O <br /> N CONTRACTOR ADDRESS P O Box 7169 Auburn CA CA LIC # 692238 CLASS A Gen. 4+".Z.. <br /> TX No_ WORK-COMP.# 692-95-2699 <br /> YES <br /> R HAZARDOUS WASTE CERTIFIED _ <br /> A PERMIT Al <br /> C FIRE DISTRICT 2 5 <br /> T <br /> 0 BOARD OF EQUALIZATION # SRKHA99-550779 <br /> R <br /> TAL(�c ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- v7/b8, 9000 Unleaded Casoline DATE-L/9 <br /> T 39- - remlum n ea a aS <br /> 1 98 <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A L,� `SEE ATTACHMENT WITH CONDITIONS) DATE Z <br /> N PLAN REVIEWERS NAME II"" <br /> I I I I I III <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 /> "1 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 CALIFO --� <br /> APPLICANT'S SIGNATURE: TITLE DATE IZ—V'-1 -a1 <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknow Ledge this responsibility for the additional billing by signature and date below. <br /> Name Woolsey Oil Inc . <br /> Mailing Address 166 Frank West Circle , Stockton CA 95206 <br /> Day Phone Number (209) 948- 412 <br /> Signature Date iL-�fr-i7 <br /> EH 23 0 ( w r2795, DST Reg's May 5, 1994) <br /> UST SYSTEM DRAWING INFORMATION <br /> 4 <br />