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i <br />i <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br />APPLICATION FOR INSTALLATION OF IADERG.ROUND TANKS AAE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT WAS BEER ISSUED. <br />A PERMIT MAY M EXTENDED INTO TME NEXT CALMAR YEA;t IF A LETTER IS SENT TO PHS-E`IO REGMSTING THIS EXTSKSION TKsRTX DAYS <br />PRIOR TO THE MOF THE CALEWDAIR YEAR. A ONE YEAR -- ONE TIMIE OrTEWsloW MAY BE GRAXTID BY PHS-EHD L.'ON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN AXY SMDED ARIJAS. <br />I <br />EH Z3 008 (Rev 1/7/92) WP <br />pove 3 <br />3 <br />t * d r, I : t' 1 C G +' C• 7- ;' 0 1 W �� j <br />INE <br />EPA SITE <br />PROJECT CONTACT i TELEPHONE iF�vRJII�IC�i.I0-GiG,ZI <br />F <br />FACILITY NAME ��� �G S �MP>j�i � <br />PHONE 9 <br />CADORESS <br />I <br />_.� <br />` <br />CROSS STREET 15cJ,I� R <br />�C7E <br />T <br />OVWER/OPERATOR j <br />pHA <br />T <br />CONTRACTOR NAME �' CowS v(� I�j� <br />PMOICE ZD I, 3SCo���g31O��' <br />YVE <br />N <br />COIITRACTOR ADQRESS :/" c / F" 1 aSE RI% . <br />CA LIC �GJGj C' I �,G�AD <br />R <br />I HAZARDOUS WASTE CERT"J_FI``,'ED, YES_✓_ R0� <br />WORK.CXiFAF.#Q� HL6 W+pHp-• <br />i <br />I <br />A <br />C <br />FIRE DISTRICT M�►�►TF' >2E� <br />PER#fJT # OCT <br />r <br />0 <br />BOARD OF EQUALIZATION # <br />R <br />tttttttttttntttttttttttt�tttt <br />TANK ID TANK SIZE CHaICALS TO BE STORED PROPQSO INSTALLATION <br />O I2Y 000 IWIF <br />39- zS'5r-1 - <br />r <br />39- sV 2% bOo L <br />A <br />39- zs Fr 7 - o <br />x <br />39- <br />K <br />39- <br />9 -39-39- <br />39- <br />39- <br />P <br />P <br />L <br />APPROVED AFQROYEA WITH CONDITION(S) -�_ OJ&APPROYED <br />A <br />_ <br />TACHMNT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME OATS <br />ttttttttttttttttttt� � �tttt � <br />APPLICANT MUST PERFO'Jt ALL WCRK IN ACCORDA.*C£ VITH SAN JOAQUIN Cf7AtlETY ORDINANCES, STATE LAWS, AM MILES AND REGULATIONS OF <br />SAN JOACXIIN COUNTY PUBLIC HEALTH SERVICES. OWNER 09 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING'- 11I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PEEMIT IS ISSUED, I SHALL ROT EMPLOY ANY PERSON IN SA1CH A KANNER AS TO SECLBif: <br />Ij <br />SUBJECT TO WORKER'S CMPENSATION LAMS OF CALIFORNIA." CCNTRACTOR'S HIRING OR "CONTRACTING SIGNATURE CERTIFIES THE F(XLOWING:i <br />"I CERTIFY THAM IM THE PEkfcR MCE OF THE AIPK FOR W141CH THIS PENT IS ISS4kD, I SHALL ENPLOY PERSONS Ss18JECT TO 909-IMRIS <br />COKPEMSATION LAWS Of CAL FORKIA.' <br />APPLICANT'S SIGNATURE! I. TITLE Clt:>12b/.. Dior. �d'2�!•�IZ <br />%[Il?bJe6,-T <br />EH Z3 008 (Rev 1/7/92) WP <br />pove 3 <br />3 <br />t * d r, I : t' 1 C G +' C• 7- ;' 0 1 W �� j <br />INE <br />