Laserfiche WebLink
17HLI� TI`.kS AIM WIST 6c- �%eD PZVP40 ' WW <br /> PPWCT k \jRPb(Z Riacovm-y PlplN6V IS -M BL IN U, <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 IF A LETTER IS SENT TO PNS-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-EHO UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE Y�I' PROJECT CONTACT 8 TELEPHONE # 'A Z <br /> F FACILITY NAMEO O ,PHONE # -1 0 3 <br /> A <br /> C ADDRESStAjtqP-j— Ha�fCK, <br /> I <br /> L CROSS STREET <br /> Y CQUIW13 FJJ�IL� 41SVr �C _ <br /> T OWNER/OPERATOR PHONE # <br /> qZ5 -7 - 31 <br /> C CONTRACTORNAME PHONE # '73424-50 <br /> _ <br /> 0 L <br /> N CONTRACTOR ADDRESS _ CA LIC #. CLASS Cu <br /> R HAZARDOUS WASTE CERTIFIED YES_ NO_ 33(] WORK.COMP.# <br /> A <br /> C FIRE DISTRIC[� I - PERMIT 9 <br /> T 1 <br /> 0 BOARD OF EQUALIZATION it <br /> R <br /> T <br /> IIIIIIIIIII11111111111111 <br /> TANNKK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- ' �' S�U DATE ll <br /> T 39- 1<' �.6Eli( i I <br /> 1 <br /> A 39- <br /> N 39- _ <br /> K 39- <br /> 39- <br /> 39- <br /> IIII <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A -! /� / SEE ATTACHMENT WITH CONDITIONS) 7 d <br /> N PLAN REVIEWERS NAME DATE <br /> Illilllllllllllllllliilil I-f�fillllfl7ili I11 I I1111111111I 11111 Illilfllllll III1111II I 1111 II <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 /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." / <br /> APPLICANT'S SIGNATURE: TITLE LoF.. Ma ... DATE /0 / <br /> Indicate the responsible party to be biLLed for additional PHS-EHD Staff time expended beyond the 8 hour minirm installation <br /> payment.(ppp�The party must acknowledge,this respo'n1si�bi-Lity for the additional billing by signature and date below. <br /> Name 1 l- �A,IIN tY-(\1 <br /> Mailing Address L U <br /> Day Phone Number 25 33 - 25 3 -LISS <br /> �8 Gt -1 <br /> Signature Date -'-"-� �-2 l`I <br /> EH 23 008 (Rev 12/13/9ff Iteg's Nay ) <br /> 4 <br />