COMPLIANCE INFO_1985-1993 - Laserfiche WebLink

Home Browse Search

n n 1001011 kyj I A 011■ _� ■ i APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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 YEAR -- ONE TIME 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 party must acknowledgethisresponsibility for the additional billing by signature and date below. Name 4P�MlC1/C L.2Cl�1P r hC Mailing Address 3750 Adzurt^ F��uC.� �� >CtCi`C1M(!� l '77. .g Day PI Signa EH 23 008 (Rev 1/7/92) WP K EPA SITE 6 PROJECT CONTACT & TELEPHONE # "tfucn SCS CCI 16 q9 S;-7 a(v aV, F FACILITY NAME u� _ PHONE ; l Ql` 1 -( A C ADDRESS 31S- d U n f o I L CROSS STREET L—(n Scey, f f I T OWNER/OPERATOR pL�( C_V`C a t' PHONE # (Sco) g13 g).4 Y C CONTRACTOR NAME' PHONE # (Ci(b t7 f fl lA t` n O1_`6dQ C 0 N CONTRACTOR ADDRESS -�- CA LIC # SC�2o CLASS MLP !t_�4?1tf�QV� T R HAZARDOUS WASTE CERTIFIED YES X NO WORK.COMP.# A C FIRE DISTRICT � PERMIT # (11 WUn` lU{ 0 BOARD OF EQUALIZATION # 6-j19Iq ��M`�- u,w,J afcf RCv,� 111111111111111111111111111111 TANK ID # TANK SIZE �'�t�l �. oc) CHEMICALS TO BE STORED PROPOSED INSTALLATION 39- ULac I *,7.- 120-431)ATE T 39- A 39- N 39- K 39- 39- 39- P 1111 L APPROVED _ APPROVED WITH CONDITIONS) s DISAPPROVED A( SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME IIIII111111111111111 IIII I DATE I 1 II 1 111111 I II IIII I 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." ILI c �K`�I� n�tl APPLICANT'S SIGNATURE: `. TITLEJ��'F DATE Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The party must acknowledgethisresponsibility for the additional billing by signature and date below. Name 4P�MlC1/C L.2Cl�1P r hC Mailing Address 3750 Adzurt^ F��uC.� �� >CtCi`C1M(!� l '77. .g Day PI Signa EH 23 008 (Rev 1/7/92) WP K