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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. PROJECT CONTACT: CONTACT PHONE# d1'1 I cµ A E L UJA �.�o n( '?/C . 3 �— FACILITY NAME: (Z , CAFE FACILITY PHONE# N 0 9F- FACILITY lEFACILITY ADDRESS: +13, N, C leo R aD o A vE CROSS STREET: "PA M 14L OWNER/OPERATOR F1Z.Ep C S FAµD 1 a M y PHONE: yo r- g0 } _ 9 $3 ti CONTRACTOR NAME: Lt/ALTpnt EµC�1.tEE�2.�►L( , T7+ct PHONE: 9/!6 3 }; - ItS- z. CONTRACTOR ADDRESS: P-0 . 8 a K 0 2 s- A, Q W S A-(,ro A q s6 9 i CA LICENSE# 6 f Z j y CLASS: NAz, X13 'i Z } - 02- RnARD OF EQUALIZATION # TANK ID# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE 61 30, 00o ASo1, i&(.F - $4- ( i 1103 07-- / s," coo C: A.S.0 1106(# - q, 1 6 /I y /a 3 O 3 6 , too 0 'b IL Es EL (0 19 /Ox APPROVED "APPROVED WITH CONDITIONS DISAPPROVED (see attachment with conditions) PLAN REVIEWER'S NAME_ L��_��.d/t �I .kms_ DATE_- =- -Ui APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." C TRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WH C�IS RMIT IS ISS D,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: _— _-- — —_ TITLE — DATE S 3 Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name--- — W 0, i,TO-1 E04 t'La-1,E.E-2,-c�� *+_L- — Mailing Address P�40 J�0 X_-cc 2 S 2 A,W�ti 4 4?,5-6 1 f Day Phone Number C Signature L�' Date_— EH 23 008 (Rev 3/15/02) v G� U�n / tte,�-, lel--- L� �Z*�,� 4