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11 <br />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 IFA LETTER IS SENT TO PHS -END REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS -END UPON RECEIPT OF THIS LETTER.' <br />DO NOT WRITE IN ANY SHADED AREAS. <br />Indicate the responsible a/r to be lied forladditionaL PHS-EHD staff time expended beyond the 8 hour minimum installation <br />P <br />payment. The party must acknowledge <br />nouledge his responsibility for the additional billing by signature and date below. <br />Name EM4 4 Le,� <br />Mailing Address <br />Day Phone NumCer I -2,C /"157 - `T <br />Signature <br />EN 23 008 (Rev } /13 5)dg' May 5, <br />Date i 7, 01 <br />EPA SITE # <br />PROJECT CONTACT 8 TELEPHONE # qyz. y06 • Ss53 R <br />F <br />FACILITY NAME PA G> I we fD46A i;od 4. Lets <br />PHONE # - 01:5-3 9/� <br />A <br />C <br />ADDRESS (.78 N. W11$6A) WQ CA• <br />I <br />L <br />1. <br />CROSS STREET t"YG2 PAO t 6 Yevd <br />I <br />T <br />Y <br />OWNER/OPERATOR <br />PAQI Inlc ,,D&A-Fm44Ler( <br />PHONE # <br />C <br />CONTRACTOR NAME <br />PHONE # <br />0 <br />N <br />CONTRACTOR ADDRESS <br />CA LIC # <br />CLASS <br />T <br />R <br />HAZARDOUS WASTE CERTIFIED YES_ NO_ <br />WORK.COMP.# <br />A <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />BOARD OF EQUALIZATION # <br />R <br />111111111111111111111111111111 <br />TANK 1D # TANK SIZE CHEMIC LS 0 BE STORED '•- A_ PROPOSED INSTALLATION <br />39- :/t/fO� ��I� /a �/{y 1-C IkI It Wt IAU WPGrCA DATE ZCCJ <br />T <br />39-- GAcoLi:!. <br />A <br />39-- <br />N <br />39-0 <br />[ m LZL <br />K <br />39- <br />I QjI O d 0 <br />2020 <br />AIVLl- <br />39- <br />39- <br />11111111111 IH <br />/� <br />P sv� x'040' T'/t'� � / APP D APPR J6T ITlT"CONDI I ! ( ) D APPROVE �5� y <br />A i� EE ATTACHMENT WITH CONDITIONS) <br />�, <br />N PLAN REVIEWERS NAME /J(�l-i'i_Lt / Q DATE <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 WHICHTHI RMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF A IFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />1-1 CERTIFY THAT IN THE PERF MANCE OF T RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIF R IA." <br />t,/ TITLE A�IG?�ST DATE Z <br />APPLICANT'S SIGNATURE: ,�iAii=2� <br />Indicate the responsible a/r to be lied forladditionaL PHS-EHD staff time expended beyond the 8 hour minimum installation <br />P <br />payment. The party must acknowledge <br />nouledge his responsibility for the additional billing by signature and date below. <br />Name EM4 4 Le,� <br />Mailing Address <br />Day Phone NumCer I -2,C /"157 - `T <br />Signature <br />EN 23 008 (Rev } /13 5)dg' May 5, <br />Date i 7, 01 <br />