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• • ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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 PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS -END UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The par must acknowledge this responsibility for the additional billing by signature and date below. Name ( S ,�.�.,J/� R L R c Mailing Address J 0 Y V E� T I, dT- • Day Phone Number — 5- Y of G Signature Date EH 23 008 (Rev 1/7/92) WP 9 EPA SITE # PROJECT CONTACT & TELEPHONE #%1� ' LA S 32 _ S 9 F A FACILITY NAME � V � C; 1 � PHONE # —5"�� q C I ADDRESS 1 r I T C L I CROSS STREET S's T Y OWNER/OPERATOR--� ^ L 1�1IR PHONE # �� i s J C CONTRACTOR NAME rn PHONE # 0 N CONTRACTOR ADDRESS ` CA LIC # CLASS r r 1 T ` r/ 7 RHAZARDOUS A WASTE CERTIFIED YES NO WORK.COMP.# ®V ALL C FIRE DISTRICT i PERMIT # T 0 BOARD OF EQUALIZATION # R Illilllillllilllllllllllllllll TANK ID # TANK SIZE GO— � i G CHEMICALS TO BE ,STORED PROPOSED INSTALLATION 39- l- _ VN I DAT T 39- —6,6 6,C)OU 6 AFC V IV L, P 4. Yr► v an --.7 (� S A 39- Foo 67At UIVL Ear:)640 u5 G N 39- _Z' K 39- 39- 39- P II11 L APPROVED- APPROVED WITH CONDITIONS) DISAPPROVED A _ (SEE ATTACHMENT ITH CONDITIONS) N PLAN REVIEWERS NAME l/t/ Iilllllilllllillllii I I DATE �' ! 11!!11 I I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOA"IN OUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. 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." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." _ �J APPLICANT'S SIGNATURE: !✓Vt r /� p'L"& TITLE 0 W AJ 4 � DATE Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The par must acknowledge this responsibility for the additional billing by signature and date below. Name ( S ,�.�.,J/� R L R c Mailing Address J 0 Y V E� T I, dT- • Day Phone Number — 5- Y of G Signature Date EH 23 008 (Rev 1/7/92) WP 9