Laserfiche WebLink
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 PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # © �/� PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME IC)C) PHONE <br /> A <br /> ADDRESS l <br /> L CROSS STREET <br /> 1 � O <br /> T OWNER/OPERATOR PHONE _ <br /> Y dMor Aam �olnPl-�,111 <br /> 1-7 <br /> C CONTRACTOR NAME PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC # CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICT N _ \ \ _ \ _ PERMIT # <br /> T _ <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> Illtllllllllllllllllilllllllll <br /> TANK 10 # TANK I CHEMICALS TO 8E STORED PROPOSED INSTALLATION <br /> 39- - ( /��,- 3 .7 C-L DATE <br /> T 39 j .y. < <br /> A 39- y Cj <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> II11 <br /> P <br /> L AP VED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME -� DATE ` Z <br /> 1111111111111111111 I I III II 1 111111 <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 1S 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 TITLE DATE / <br /> Indicate the responsible party to be billed for additional PNS-END staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge <br /> this responsibility the,/aitiional billing by signature and date below. <br /> C1-1 <br /> Mailing AddressC� <br /> Day Phone Number { 1jC6'/ <br /> Signatures ,r— I-YVDate `� I <br /> EH 23 008 (Rev 12/13/95, UST Reg's May 5, 4) <br /> 4 <br />