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0 <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-EHO REQUESTING 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 SHADED AREAS. <br />Indicate the responsible party to be billed for additional PHS -END staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name <br />Mailing Address <br />Day Phone Number <br />Signature Date <br />EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) <br />0 <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # C4 I L' 36 Z Z { Z .4 <br />F <br />A <br />FACILITY NAME Loa 1 t Q o v m $ F00 ® Srro QG <br />PHONE # <br />C <br />I <br />ADDRESS 1 Z Z WEF-.5 T t_c) Gl<.Fo re <br />L <br />CROSS STREET RAM (-o<-- Fcj l2 0 <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />I tda,AMem%t< 5-tN4rR <br />z0q-- 333- G <br />O <br />I CONTRACTOR NAME 1-,. M Co N S C✓ dQ <br />PHONE # <br />t � c®Z-ZtZ <br />N <br />CONTRACTOR ADDRESS U = <br />11 <br />CA LIC # <br />,�pt .Z <br />CLASS <br />T <br />oe <br />$ A56 H <br />R <br />A <br />HAZARDOUS WASTE CERTIFIED YES ---' NO <br />WORK.COMP.# <br />EX'�etilt�?- <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0r39- <br />EQUALIZATION # <br />R <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />DATE <br />T <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />111! <br />L <br />APPROVED _ APPROVED WITH CONDITION(S) <br />DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />IIII fill IIIIII I I I 1111111111111111111111111111111111111111111111111111! I 1111 <br />DATE <br />1 111 II111111 IIIIIIIIIIIIII1111 1111111111 <br />APPLICANT <br />MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />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 <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I <br />SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: Ide TITLE <br />DATE <br />Indicate the responsible party to be billed for additional PHS -END staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name <br />Mailing Address <br />Day Phone Number <br />Signature Date <br />EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) <br />0 <br />