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f. <br /> 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 B7 PHS-EHD UPON RECEIPT OF THIS"[ETTER.... ._.. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # 55 7 PROJECT CONTACT a TELEPHONE O J OH N <br /> A FACILITY NAME PHONE #/'^�;T _47 5�l <br /> C ADDRESS ���2 �i �..�,�„N`,P`�1 t '� <br /> L CROSS STREET <br /> I t <br /> T OWNER/OPERATOR _ _ <br /> Y �U` AJ�� :; 1 NS�iG, PHONE # <br /> C CONTRACTOR NAME � —r <br /> � -- <br /> PHONEO # 2 _� <br /> ""' t✓ <br /> T CONTRACTOR ADDRESS / W 1 L.L Jed ex <br /> f L k, N; .,y, CA CIC — a CLASS �,Z, <br /> R HAZARDOUS WASTE CERTIFIED YES L-1 No <br /> A <br /> WORK.COMP.» <br /> CFIRE DISTRICT'* . .._fir, '` <br /> T -: pq 1" ."?l PERMIT » <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> IIII[Iltllllllitlltltlllllllll <br /> TANK ID a TANK SIZE <br /> 3CHEMICALS TO BE STORED PR INSTALLATION <br /> 9- t2 �utT <br /> A —J/ , ,�a•G t i� t/1`bL Lam— c` E <br /> N 39- —L(' <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 939- <br /> 39- <br /> P <br /> L APPROVED _ APPROVED WITH CONOITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> H PLAN REVIEWERS NAME DATE <br /> IIIlttlltltltl!!lltl I 1 I 1 I tttll I <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 AGENTOS 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." CONTRACTORIS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI " a <br /> APPLICANT'S SIGNATUR <br /> TITLE 141-11F'27 GG'f2,'T�/i: DATE <br /> Indicate the responsible party to be billed for additional PHS-EIB) staff time expended beyond the 8 houc minimum installation <br /> payment. The party must acknowledge this responsibi.tity for the additional bftting by signature and date below. <br /> Name�FH Lr�1�J <br /> Mai l in Address G�,'"�2lS.t�1G�f� �A <br /> Day Phone NumberI :Ll <br /> Signature Date <br /> EH 23 0 17J, UST Reg•s'May S, 1994) <br /> 4 <br />