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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-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br />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. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />Indicate the responsible party to be billed for additional PHS-EHD 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 Oil Equipment Service <br />Mailing Address P.O. Box 950, San Andreas, CA 95249 <br />Day Phone Number 209-754-1808 <br />Signature Date 10/24/98 <br />EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994 )Keith A. Tallia, Pres. <br />4 <br />EPA SITE #CAC 001081776 PROJECT CONTACT & TELEPHONE # Keith A. Tallia 209-754-1808 <br />F <br />FACILITY NAME Waterloo Food & Fuel PHONE # 209-466-5816 <br />A <br />ADDRESS 3032 E. Waterloo Rd., Stockton CA 95205 <br />L <br />CROSS STREET Sutro <br />I <br />T <br />OWNER/OPERATOR PHONE # <br />Y, <br />Gurj2al Sidhu et.al. 209-466-5816 <br />I CONTRACTOR NAME Cil Equipment Service PHONE # 209-754-1808 <br />0 <br />TCONTRACTOR <br />ADDRESSP.O. Box 950, San Andreas, CA <br />CA LIC # 323417 i CLASS A-Haz r <br />R <br />HAZARDOUS WASTE CERTIFIED YES_X_ NO 5249 WORK.COMP.# 265057 —, <br />A <br />C <br />FIRE DISTRICT San Joaquin County PERMIT # <br />T <br />0 <br />BOARD OF EQUALIZATION # <br />R <br />�lliflillfl1f1111111111111!lIII � <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- 3 10,000 RReaul r nl s lin DATES_ <br />T 39- d Casolifte <br />A 39- 4,UUU Diesei Fuel <br />N 39- <br />K 39- 111 <br />39- <br />39- <br />d <br />1111 <br />P <br />L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A e ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />fltllilllll1111111111 III II11 111 II1 Ilill I II !1 II111 11 11!lillllll!! 1111111 I II111 1 1 III11ill it 1 <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 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFO .-. <br />i <br />APPLICANT'S SIGNATURE: ( TITLE Agent DATE 10/24/98 <br />Ajdi�Eh A. tall a <br />Indicate the responsible party to be billed for additional PHS-EHD 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 Oil Equipment Service <br />Mailing Address P.O. Box 950, San Andreas, CA 95249 <br />Day Phone Number 209-754-1808 <br />Signature Date 10/24/98 <br />EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994 )Keith A. Tallia, Pres. <br />4 <br />