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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. s, <br /> EPA SITE # PROJECT CONTACT & TELEPHONE #STLUF ��;�1R,t,ylSi$Ii„ 167-6Qv-7,g I cl <br /> F FACILITY NAME 'PAC_, ( .__. r' PHONE # <br /> A <br /> C ADDRESS G41S A\jm Tock 7(3)kJ <br /> 1 <br /> L CROSS STREET <br /> 1 Z 0L) C�Li. t_ <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> C CONTRACTOR NAME �� L 3 PHONE # 70Z-�93 -292,8. <br /> 43 C <br /> N CONTRACTOR ADDRESS id T��N7AIM R� CA LIC # J 7� �. CLASS A, 11 Afl� <br /> T I <br /> R HAZARDOUS WASTE CERTIFIED YES <br /> NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK AI����I��������� <br /> TID g TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- SKS-3 7 S k tAl l oYJ Ri'.6 tI L'\A UVj%-faAJyr4•I1 14 DATE <br /> T 39- Otit.tcc\ciln <br /> N 39- <br /> K 39- <br /> 39- <br /> 1111111111P <br /> L APPROVED APPRO D WITH CONDITION(S) _ DISAPPROVED <br /> A ( EE CHMENT WITH CONDITIONS) Q , <br /> N PLAN REVIEWERS NAMEp �(. � \ DATE < <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WI SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWN R OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PE IT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALI ORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT IN THE PERFORM CE OF THE K FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFOR� ." <br /> f- `- <br /> APPLICANT'S SIGNATURE: I/3.` -"\ TITLE A4NIF64 MArd:O 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 WN r(?W�ADLI (> -TN c 'j' Q — <br /> Mailing Address qT lD �N OW I 6 �0 <br /> Day Phone Number 707 � -} r 9 q 2, / `67 �j <br /> 9 3 - 7 1-1 <br /> Signature % TT-. / Date <br /> EH 23 008 (Rev 2/13/95, UST Reg's May 5, 1994) <br /> 4 <br />