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10 'P�/S- F4 U )r7�1�lry <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br />APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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 YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE # CAL 920 604 834 PROJECT CONTACT & TELEPHONE # Chester Bennett ( 91 6 ) 635-244 <br />F FACILITY NAME ANASTASIO' S AM PM MINI MART PHONE # 209 835-1605 <br />A <br />C ADDRESS 3425 Tracy Blvd Tracy, CA <br />I <br />L CROSS STREET Clover Road <br />I <br />T OWNER/OPERATOR PHONE # <br />Y Jack Anastasio (209)-835-1605 <br />C CONTRACTOR NAME Golden West Builders PHONE #(510) 447-2484 <br />0 <br />N CONTRACTOR ADDRESS567 Exchange Ct, Livermore CA CA LIC # 4321 03 cLAss <br />T <br />R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# 001486-92 <br />A <br />C FIRE DISTRICTTracy Fire District PERMIT # <br />T <br />0 BOARD OF EQUALIZATION # 44-000506 <br />R <br />TAyK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- (� _ DATE <br />T 39- <br />A 39- O e e ermine a' <br />N 39- Tin fi493 <br />- <br />K 39- <br />39- <br />39- <br />II11 <br />P <br />L APPROVED APPROVED ITH CONDITION(S) a DISAPPROVED <br />A (SEE TACH WITH CONDI ONS) <br />N PLAN REVIEWERS NAME DATE <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 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 RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." �% <br />APPLICANT'S SIGNATURE: TITLE&1111L �Tl&—I,s JATE <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name ARCO Products Company Attn: Cora Cabrea <br />Mailing Address 17315 Studebaker Rd, Cerritos, CA 90701-1488 <br />Day Phone Number (21;�baker Rd, Cerritos, CA 90701 -1 488 <br />Signat <br />EH 23 008 (Rev 1/7/92) WP <br />Permit Specialist <br />3 <br />Date ' �� <br />