COMPLIANCE INFO_1995-2004 - Laserfiche WebLink

Home Browse Search

1 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 CALCAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A CNE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD 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 party must acknowledge this responsibility for the additional billing by signature and date below. Mailing Address � © u U Day Phone Number © 11 / 1 Signature Date EH 23 008 (Rev 1/7/92) WP / �k / oC�r a 0 ✓ �-ey„�c,� . EPA SITE #C/ � PROJECT CONTACT & TELEPHONE # �� ` 5w 53 7p F FACILITY NAME VL.0 PHONE # A O ADDRESS 25-75 L CROSS STREET �j� ,S ' 6 / 3 0 ILi T OWNER/OPERATOR PH � # '-�6 7�Y s ` �T C CONTRACTOR NAME v Srg�jI CIES PHONE # gp N CT CONTRACTOR ADDRESS 5 6'7 ��G e l l OUP— CA LIC # CLASS LIQV-r�aje_l G T 71 R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# A C FIRE DISTRICT S PERMIT # T 0 BOARD OF EQUALIZATION # H2 - 10 1 7 7 R illlllllllTAIK llililllllllll TA IK ID # 7JUiK SIZE ISi f CHEMICALS TO BE STORED PROPOSED INSTALLATION S DATE 39- T 39- a A 39- N 39- K 39- 39- 39- P L IIII APPROVED APPROVED WITH CONDITIONS) DISAPPROVED A a (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME t! �L - ~ ` 11111111111111111111 I I �lrl-ff11Tt(�i DATE 1 I I I I I ITiTf ii�l l l i l l I 1 1 11 1 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY 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 rPERMIT 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 "K FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." / SIGNATURE. L O--yl� TITL 204�rJ d DATE APPLICANT'S Indicate the responsible party to be billed for additional PHS-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. Mailing Address � © u U Day Phone Number © 11 / 1 Signature Date EH 23 008 (Rev 1/7/92) WP / �k / oC�r a 0 ✓ �-ey„�c,� .