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F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <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 PHS-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 IN ANY SHADED AREAS. <br />EPA SITE # (�,�C'DQ� b ���� <br />FACILITY NAME KHAL' S ARCO <br />ADDRESS 701 E CHARTER WAY <br />CROSS STREET STANISLAUS STREET <br />OWNER/OPERATOR KHALDOON & NOURI <br />PROJECT CONTACT & TELEPHONE # <br />CONTRACTOR NAMECRISP PETROLEUM ENVIRONMENTAL <br />CONTRACTOR ADDRESS 433 N ATWOOD <br />HAZARDOUS WASTE CERTIFIED YES X NO <br />FIRE DISTRICT CITY OF STOCKTON <br />BOARD OF EQUALIZATION # <br />PHONE # (209)467-0305 <br />PHON # <br />(209)467-0305 <br />PHONE # 800-359-2747 <br />CA LIC 9 O FILE I CLASS ON FIL <br />WORK.COMP.# ON FILE <br />PERMIT # PENDING <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- ONE 1_ , 000 TTNT.FATIFTI GASOLTNE j.j./.936ATF._ <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />� � � � fTTIRTTTTTT1TiTf1T <br />P <br />L _ APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A (SEI: ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME ATE _ <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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: V, -L Z22 Z6� 4- TITLE e,LVjfiC� DATE / 1 <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name L ✓' l � � �? .P � - - - - <br />Mailing Address <br />Day Phone Number <br />Signature <br />EH 23 008f Oev 1/7/92) WP <br />G <br />Date ;2 — 17— — <br />