Laserfiche WebLink
AA <br /> ENVIRONMENTAL HEALTH DIVISION ffz 40 <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS KEN ISSUED. <br /> A PERMIT CAN BE EXTEMM INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-END REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION NAT BE GRANTED BY PNS-END UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SPAM AREAS. <br /> EPA SITE i PROJECT CONTACT iTELEPum it -� <br /> F FACILITY NAMEST <br /> _a C PH= i _ _ / <br /> A <br /> SS .S S <br /> I I C <br /> L CROSS STREET Po R 77 <br /> H ' <br /> T TOR PUCK i <br /> Y 1-!m <br /> ® CONTRACTOR NAME ® PHONE <br /> i <br /> N CONTRACTOR ADDRESS �, ads®,9 a Lac i 3 CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES_Z NO WORK.COM'-! /l <br /> A <br /> C FIRE DISTRICT PERMIT i <br /> T <br /> 0 BOARD OF EQUALIZATION i <br /> R <br /> 111 i 11111111111!11111111111111 <br /> TANK ID i TANK SIZE CNENICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- 10 ® ,7` FL,.,6-c- DATE <br /> T 39- O ®o EJ` vet <br /> A 39- <br /> N 39- <br /> K 111111111 fill 11111111111111111 Ill III 1111111111111111111 <br /> P <br /> L 4 APPROVED WIT ITION(S) _DISAPPROVED <br /> A ,7 (SEE AG N CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 1111Illtlllli1111111 11111 <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 LICEMSEII AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: ■I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT ISI , I SNALL NOT ANY PERSON IN SUCH A AS TO BECOME <br /> SUBJECT TO 'S COMSATION 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 -S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: <br /> TITLE DATE Z <br /> EN 23 000 (Rev 1/7!92) WP Pape 3 <br /> 3 <br /> . e, <br />