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• J ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT 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 1N ANY SHADED AREAS. S Indicate the responsible party to be billed for additional PHS -END staff time expended beyond the 8 hour minimum installation payment. The party musts acknowledge this responsibility for the additional billing,by signature and date below. Name R� Mailing A Day Phone Signature Date lQ - a—f EH 23 008 (Rev 1/7/92) WP t i - A M"Z� 0lc� . EPA SITE #000�,�1)3$ �� PROJECT CONTACT 8 TELEPHONE # �J,P F FACILITY NAME A7/li PHONE # 94 b, A C ADDRESS 1 , �SOAI 67VCV-7ai�/ ,3-7L� . T L CROSS STREET I Y OWNER/OPERATOR/ /� _ PHONE jY'jj�/�.�� I# C CONTRACTOR NAME �� %�yG �� PHONE /0 .3-42— 0 N CONTRACTOR ADDRESSs-r Q�ub W _ CA LIC # I-I,q ZQ 1 v CLASS A T R HAZARDOUS WASTE CERTIFIED YES ice" NO WORK.COMP.# C - (gA,140-t A C FIRE DISTRICT e�/1-7-4J PERMIT # T 0 BOARD OF EQUALIZATION # R T39- TANK ID # ANK SIZE CHEMIC1�L �Tp BE STORED PROPOSEDDINSTA (�aa��-JJ`` ��JJ T 39- — A 39- N 39- K P IIIIIIIIIIIIIIIII L APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE TfflTW 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 FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." / APPLICANT'S SIGNATURE: / ,,.++�� (( / TITLEJF C.-�A1NLff, DATE S Indicate the responsible party to be billed for additional PHS -END staff time expended beyond the 8 hour minimum installation payment. The party musts acknowledge this responsibility for the additional billing,by signature and date below. Name R� Mailing A Day Phone Signature Date lQ - a—f EH 23 008 (Rev 1/7/92) WP t i - A M"Z� 0lc� .