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SAN AQUIN COUNTY PUBLIC HEALTH S ICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The pat must ac now® ge this responsibility for the additional billing by signature and date below. N ame Mailing Address Day Phone Number, Sifhkture EH 23 008 ( ev 127t3/95, US Reg's May 5, 1994) UST SYSTEM DRAWING INFORMATION 9 W10 < Date_ EPA SITE #jjA �f 0014030 4 PROJECT CONTACT & TELEPHONE # F FACILITY NAME PHONE # A C ADDRESS 3 I L I CROSS STREET T OWNER/OPERATOR ' PHONE # vzz- CONTRACTOR NAME • PHONE # D 9- q1A 4:747 OC N CONTRACTOR ADDRESS ' CLASS i CA LIC # 4 i W R HAZARDOUS WASTE CERTIFIED ES NO WORK.COMP.# 9 _ 7 -9 o:Z C FIRE DISTRICT PERMIT # T 0 BOARD OF EQUALIZATION # R ® ` i 111111111111111111111111111111 TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION 39 -DATE q8 T 39- / p gam® A 39- N 39- K 39- 39- P llllllllllll1111111111 1111111 111111111tlIII1111l111111{II11Itrllttll11111111111111111111ti11111111111iltlllttlltttlllllllll L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME 11111111111111111111 DATE I 11111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: Q TITLE DATE Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The pat must ac now® ge this responsibility for the additional billing by signature and date below. N ame Mailing Address Day Phone Number, Sifhkture EH 23 008 ( ev 127t3/95, US Reg's May 5, 1994) UST SYSTEM DRAWING INFORMATION 9 W10 < Date_