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7 0 ENVIRONMENTAL HEALTH DIVISION 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. 111111 1 1 1 1 1 TANKI 1 pl #1 1111111 I I I 39- 3 39- A 39- N 39- K 39- 39- 39- P 1111 L A 1 TANK SIZE I C GALS TO BE STORED APPROVED X APPROVED WITH CONDITIONS) ® DISAPPROVED a t. n PAWE ATTACHMENT WITH CONDITIONS) NSTALLATIONI N PLAN REVIEWERS NAME DATE 11111111111111111111111111 liiiiiiiiiiiiiiiiniiiillillilillillilI111111 1 1 1 1 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 PERFORMA CE OF THE WORK F WHd THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORN Go APPLICANT'S SIGNATURE: TITLE DATE 1-- Indicate the responsible party to be bitted Tor adaisionat rnb-tnu szarT time expenaea oeyona sne o nour "n n rnRan 11MLOLLULfUll �nY— .. The party must acknowledge this responsibility for the additional billing by signature and date below. Name Mailing Address Day Phone Number Signature Date EH 23 008 (Rev 1/7/92) WP 1 tf / � e tl AN �o: iA✓�i� fid( �rr� 11 o'- *M - us-+ v- !VI #Ota i Ai X1"4 kz- ig "to ® U. h uAtri A �s l{ 61;t V\P-A EPA SITE # - PROJECT CONTACT & TELEPHONE # F FACILITY NAME ' - PHONE A C ADDRESS s I L CROSS STREET 1 T OWNER/OPERATOR PHONE # 6 3 —7— 6 -77, Y Lj��4 �,jej C CONTRACTOR NAME �' '� 9 PN E 16-- —322 0 N CONTRACTOR ADDRESS ® , CA LIC # ` CLASS T R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# A C FIRE DISTRICT PERMIT # T 0 BOARD OF EQUALIZATION # R 1 111111 1 1 1 1 1 TANKI 1 pl #1 1111111 I I I 39- 3 39- A 39- N 39- K 39- 39- 39- P 1111 L A 1 TANK SIZE I C GALS TO BE STORED APPROVED X APPROVED WITH CONDITIONS) ® DISAPPROVED a t. n PAWE ATTACHMENT WITH CONDITIONS) NSTALLATIONI N PLAN REVIEWERS NAME DATE 11111111111111111111111111 liiiiiiiiiiiiiiiiniiiillillilillillilI111111 1 1 1 1 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 PERFORMA CE OF THE WORK F WHd THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORN Go APPLICANT'S SIGNATURE: TITLE DATE 1-- Indicate the responsible party to be bitted Tor adaisionat rnb-tnu szarT time expenaea oeyona sne o nour "n n rnRan 11MLOLLULfUll �nY— .. The party must acknowledge this responsibility for the additional billing by signature and date below. Name Mailing Address Day Phone Number Signature Date EH 23 008 (Rev 1/7/92) WP 1 tf / � e tl AN �o: iA✓�i� fid( �rr� 11 o'- *M - us-+ v- !VI #Ota i Ai X1"4 kz- ig "to ® U. h uAtri A �s l{ 61;t V\P-A