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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 BY PHS -END UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />PROJECT CONTACT & TELEPHONE # C4 I (� - .�6 Z, - Z I -Z `i <br />F FACILITY NAME �.O ® t �. ill IZ Fon g S -T© 2G <br />A <br />C ADDRESS I Z Z '� WeFt T 1-.O GK FO Ill <br />I <br />L CROSS STREET ��M` t,vGlGk=�t2f� <br />I <br />T OWNER/OPERATOR PHONE # <br />Y ptvt E: fZ ► K. t Nlar H Zoy 3 3 <br />C CONTRACTOR NAME PHONE # <br />its M G'c7N5 C. O 4aZ � 2I <br />O <br />N CONTRACTOR ADDRESS T2jAZ0 CA LIC # cool g,7 3 CLASSA 1151,A-360 <br />T <br />R HAZARDOUS WASTE CERTIFIED YES �-1 ' NO WORK.COMP.#rry— <br />A <br />CMME NOW <br />T <br />0 <br />R <br />III IIIIIIIIIIIIIIIII1......... <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />34- <br />- im -in I-MENEM <br />T 39- <br />A 39- <br />.N 39- _ <br />K 39- <br />39- <br />39- <br />IIII <br />P <br />L APPROVED _ APPROVED WITH CONDITION(S) _ _ DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE, <br />1111111111111 11111 <br />.... 1. P. <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF• . F <br />SAN JOAQUIN 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 HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING! <br />"I 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 CALIFORNIA." <br />APPLICANT'S SIGNATURE: ,�F TITLE 'ye --a— DATE <br />�nalGaLe Cne respu1lt"u": pally LV <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />sfvm <br />EH 23 <br />4 <br />