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3-26-1997 9:S2AM, FROM P S <br /> 3 0 0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALT'ri DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATICN PERMIT <br /> THE APoLICATION FOR INSTALLATICN OF UNDERRGRCUND STORAGE TANKS IS ONLY VALID FCR 7HE CALENDAR YEAR IN WNICA IT HAS SEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-END RECJESTING rHls EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CAL---HOAR TEAR. A ONE TIME, ONE YEAR EXTENSION MAY 3E GRANTED BY PHS-END UPON RECEIPT OF THIS LETTER. <br /> DC NOT WRITE IN ANY SHADED AREAS. <br /> _PA S:TE N A I PRCJECT CONTACT L TELEPHONE #/AlU I — G> <br /> C ( FACIL:TY NNA,MEC /, + / L. L/1 CyZO(7� 34i 9+I ! 6 D I <br /> ADDRESS ,n"l�C] /.G� LCC <br /> I :RCSS STRw <br /> t j <br /> T � DWNER/CPE2ArOR_ P'iCNE Y <br /> ` ir1 o 12n 1r'7 <br /> C ( cONTRAc73R NAME ?NONE #6116) (' <br /> 0 ' <br /> N CCNTRACTCR ADDRESS 3 V e>4 �;--• CA LIC zL� it CdAss <br /> R 4AZARCCU'> WASTE RTIF:ED YES /'`�+ NC I : RK.MMP.�6l <br /> C I =IRE DISTRICTA�� LD6 - ( PERMIT xA. XI-�S <br /> Rf BOARD OF ECUAL:ZATICH = �® 67 <br /> I � <br /> �IIiiIlliPflANK I ltiPPIPPlEIIi t 'E, �PRcaasEO ! TAL'AT:cN' <br /> TANf, IOt TAMC SIZE � C. ICAL 7C ac STCR„� <br /> 39- / 1 r r 1� 1 <br /> iq. i t 1v r+` , I <br /> a 39. ' <br /> i <br /> N 3a- I j <br /> K 39- 1 <br /> 39- Isy_ <br /> P 11tiJ�1111111111 Jill[ <br /> /gTT <br /> L APPROVED APPROVWITH CONDITICNCS) DTSAPPRCVED <br /> A ® SEc ATT YMEHT WITH CONDITIONS) <br /> N PLAN RE-I:FJE.BS NAME // DATE <br /> dtiilildlidillildliliitliil�lTlT 71i� I1 Pllll !!II! Etillllllllll lllJill]111111111l! t !!#lEllll}ll 1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JCACUIH C^=NTY ORDTNANCES, STATE LAWS, AND RULES AND REGULAT:CNS CF <br /> SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES. OWNER CR LICENSEDi AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PEZFCRMANC: OF THE xRK FOR 'WHICH THIS PERMIT IS ISSUZ, I SHALL NOT EMPLOY ANY PERSCN IN SUCH A MANNER AS TC a£CCME <br /> SUE-'ECT 70 .CRKER'S CCMPSNSATICN LAWS OF CALIFORNIA." =NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FCLLCWITIG: <br /> i "I CIRTIFY THAT IN THE ?ERFCRMANC: OF THE WCRK FO WHTCa THIS PERMIT IS ISSUED, I SHALL E14PLOY PERSONS SUBJECT TO 'JORKER'S <br /> CZ;MPf,NSAT I CN LAWS Of CAL I FCRN I A." ��T ` G <br /> APPLICANT'S SIGNATURE: E TTTL /��///���-! �' DATE <br /> Indicate t`e responcibte parry ;o be billed for additional PHS eii0 staff time ezFended beyond t1e 8 hour minimum irs:altation <br /> oayment. pThe party must acknowledge this resperraibility for the additional bil,Hn; by signature and daze below. <br /> (-ey As <br /> {aitiMS Address 337D �Lt.�'T�er- �r� F Looms �I`I - 43S D J'T) <br /> Day Phane Nurmer <br /> Sl,riaturc <br /> Daty 312, 6 <br /> =.H 23 CC3 CRry 2/13/95, UST Reg's May S. 1991 <br />