Laserfiche WebLink
1 . I <br /> I <br /> 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-END UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE #CATosoozgIla q PROJECT CONTACT & TELEPHONE 0541f, WerC110 ?D'1-765-1660 <br /> F FACILITY NAME P <br /> A act}J.0 'g f,a FA co 1 PHONE # 334 0010 <br /> ��/ w .A <br /> C ADDRESS 1Z t{ W• w� S�fY c� Loi c rt 25410 <br /> 1 <br /> L CROSS STREET N CI,�lfl;i, �ftC/C <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y P44 �Ct( 672-5,-8z3-6�cr <br /> C CONTRACTOR NAME PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC # CIASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> 111111111111 i t 111111111111111 <br /> TANK ID TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- DATE <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> lIIIIIIIIIIIIIItIl11 II I ! 111111 <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 CALIFORNIA."— <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> Indicate the responsible party to be billed for additional PHS-END 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 <br /> Maiting Address �f!3� �• wlCppWGI� F1�U� 'C:�aC�e/wtgl C� ql / S' <br /> Day Phone Number 70�— 765— /660 <br /> Signature Date <br /> EH 23 008 (Rev 12/ /95, UST Reg's May 5, 1994) <br /> 4 <br />