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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 # t-6,11 c5- H. lLi2� (2G�� z.5 c- zzz- <br /> F FACILITY NAME 4,02do q/�lPM IAf—1 7-)/ P'k�.�� 3 PHONE # <br /> A <br /> C ADDRESS /�CC? 5 117,q/Al !� T <br /> 1 <br /> L CROSS STREET //%//#)cL/$T2/ q-jr /�A-24-, <br /> 1 <br /> T OWNER/OPERATOR A zCfi p/zc a/eT5 'CdJ�I/�AniY PHONE # <br /> Y ( "ji4� 6 7c:- <br /> C CONTRACTOR NAME / IGT ScZrtTco YEr 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 PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- &n/c C ,20csp ' ATE <br /> T 39 ?��R9t� /2��iuc.?i2 c.ivccnDr/, <br /> A 39- /a.tE� 5 gat L--L-2 <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME 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 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: '— TITLE 42L2,1.717 r6C,,,T DATE <br /> Indicate the responsible party to be billed for additional PHS-EHD 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 �'�f��i//,4(15.�/ ( /ALT//,ljd' L�ti!!.4/i✓tL/�S / ST 7D//t7✓ /�/. K/,2K <br /> Mailing Address /.6z/S <br /> Day Phone Number '2,f:; <br /> Signature — 'r� Date ?`I <br /> EH 23 008 (Rev fat 3/95, UST Reg's My 5, 1994) <br /> 4 <br />