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1 <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 1S SENT TO PHS-EHO REOUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE ENO OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHAVED AREAS. <br />T— <br />EPA SITE fe,,,Jecjal dGo 28 i�' PROJECT CONTACT &_TELEPHONE 4 ZG9' .� 5-7,2, <br />FACILINAME <br />F TY ' <br />A — ,Loy/ ,L/Qcl��' $ l�ooD �Tcv2C' PHONE B �ocT y 333-- Id 3b^ <br />I <br />ADDRESS ✓�OC ytr�yp-r7 <br />L CROSS STREETMaw a <br />1 — <br />T DWNER/OPERATOR PHONE M <br />Y ma ' 2dq- 'ji33 - ta3& <br />C CONTRACTOR NAME PHONE Nqlr 3 �„ <br />0 sof <br />N CONTRACTOR ADDRESSD µ M CA LIC M CLASS -kq 14#q Z F, <br />R HAZARDOUS WASTE CERTIFIED YES—,f% NOWORK.COMP.M XC/i11�T <br />A -- <br />C FIRE DISTRICT ! PERMIT It <br />T <br />0 BOARD OF EQUALIZATION 8 <br />I - rrnrrnrurrrrr�r�nrnrnrn __ .. <br />TANK I TANK SIZE CHEMICALS TO BE STORED PROPOSEO A NSTALLAT ION <br />39- 10 dwo y&ATE <br />T 39• — Rrt?LlJ�yc.rJ�1l- <br />A39- C <br />N 39- <br />39- <br />39- <br />P <br />9 -39-39-P immim mmumm milmum mummmmumAl I I III if III I IIII I I I I I I I I I Munn= ffflT 11=1IIIIIII <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A —� (SEE ATTACHMENT WITH CONDITIONS) y� <br />N PLAN REVIEWERS NAME DATE <br />-� rrr,rrrrr,rrrrrrrrrrr 1TmT�rnmmmmrrlmrrrrnlmr���iitmmrrrrmmttrT <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAOUIN 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 MIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, l SMALL EMPLOY PERSONS SUBJECT TO WORK£RfS <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE <br />TITLE 4^.�y�til3lt DATE _6 <br />Indicate the responsible party to be billed for additional PNS -END staff time expended beyond the 8 hour minimum installation <br />payment. The party mutt acknowledge this responsibility for the additional bitting by signature end date below. <br />Rom._ t�i�t t s r Air H Ilta I oud12 <br />Sloe s xF rr p - <br />Ma; t;ng address i' t c7E5T �aQ I<r0 0 <br />bay Phone Number , C'71 G� 'j [V _.. <br />signatully- ___dam'' 1_ Pate <br />EH 23 008 ( vV 12/1 /95, UST Rag's May S, 1994) "`2_1" <br />------ <br />4 <br />