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 ENO OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PNS-EHO UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> TELEPHONE 9 T <br /> PROJECT CONTACT d EL <br /> EPA SITE X (, JI,�.<< '' <br /> F FACILITY NAME PHONE x O 16 3 - <br /> A UNITED v <br /> ADDRESS 440 CHARTER WAY <br /> L CROSS STREET LINCOLN <br /> I <br /> TOWNER/OPERATOR PHONE # c� / <br /> Y JODHA GILL �� 1 �3�' oy�`I <br /> l a l CONTRACTOR NAME F I L PHONE X <br /> H I CONTRACTOR ADDRESS CA LIC X I CLASS <br /> THAZ— — <br /> � <br /> R I HAZARDOUS WASTE CERTIFIED YES _ NO 40RK•CG1P•» <br /> A <br /> C I FIRE DISTRICT PERMIT : <br /> T gTOCKTON <br /> 0 BOARD OF EQUALIZATION » <br /> R <br /> IIIIIIIIIl1111111111111I111111 <br /> TANK IO X TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- DATE <br /> 39- <br /> A <br /> 9 A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> II11 <br /> 1P �( <br /> APPROVE / \ APPROVED WITH CONDITION(S) DISAPPROVED <br /> A l (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME <br /> DATE <br /> (II Ilillillilllll llllllllllllllll Illlllllllllllllllllillllllllllllillllllllllll IIIIIIIIII l l llllllll 11111111111111111111 <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 /> "! CERTIFY THAT IN THE PERFOR C OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CCMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATOR ' TITLE 16ATE <br /> Indicate the responsible party to be illed for additional PHS-EHO 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.ed <br /> Namey l/ '` <br /> Mailing Address � d 8f)/` ' 1 5 � TZA (—V PA <br /> Day Phone Number <br /> � Q p <br /> Signature l Date <br /> EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1 ) _ - <br />