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SAAAQUIN COUNTY PUBLIC HEALTH SOVICES <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 PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # 1 PROJECT CONTACT 8 TELEPHONE # gill l5eN6 (gs 4(,3-Z711 <br /> F FACILITY NAME `Jov}hlana 7 e:1eVen GjIDfe ZI7 ,J& PHONE # <br /> A <br /> C ADDRESS gs1L. NebtJe' niiz' I''lan�eo3 <br /> I <br /> L CROSS STREET povJuS Ave, <br /> I PHONE # <br /> Y OWNER/OPERATOR The � y�_�ancl 6-o"porotion (q25) 4G3^2141 <br /> C CONTRACTOR NAME _�aH'1eS'J COr ration PHONE # (�2)595-4555 <br /> OCA LIC # 55333 CLASS A w'�' ISS <br /> N CONTRACTOR ADDRESS 11Q1 �. Sprirl � 12 421 627 GS7 <br /> TNOWORK.COMP.# wG$1�gp�j(p <br /> R HAZARDOUS WASTE CERTIFIED YES C _ <br /> A PERMIT # <br /> C FIRE DISTRICT <br /> T <br /> 0 BOARD OF EQUALIZATION # -rYl4GL 44 - Dom' 2251 <br /> R <br /> 1111111111 <br /> TANK 111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSEDDATETALLATION <br /> 39- <br /> 3 39- DOD X19 on oau aI- U61 <br /> A 39- O�ILS PtG" i"� HIGJ <br /> N 39- <br /> K 39- <br /> 39- <br /> 111111 1111111 I 1111 111 111111 I I III 111 1111 I 1111 I I I I 111 11111 1111 III 11 I 1111111 11111 <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> IIIIIIIIIIIIIIIIIIII IIIIII <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 /> 1-1 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 CALIFORNIA." �,,� L <br /> APPLICANT'S SIGNATURE: QM.,PiJ �►+++w of t11- C2?S �ITLE Alft fOr Gk&ISM DATE 4 1(o qb <br /> Indicate the responsible party to be billed for additional PHS-EHO staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name I;NL DCtbl n 6rou , 1nG. <br /> Mailing Addresso I"Io4JC/ Avenue, <br /> es% � # �4' r'J2Gf2i'1'IGn"f'O � G/1 g5SZ5 <br /> Day Phone Number (11&) (o4& -400-5 <br /> Signatur • Date <br /> EN 23 00 (R /13 , UST Reg's May 5, 1994) <br /> UST SYSTEM DRAWING INFORMATION <br /> 4 <br />