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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 EEXTENSION MAY BE GRANTED BY PHS-EHO UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. (7c-7) <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # J51FK L 765 144 <br /> J <br /> F FACILITY NAMEc PHONE # <br /> A <br /> C ADDRESSdG � <br /> I <br /> L CROSS STREET �MPkJ4 ry <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> CO I CONTRACTOR NAME ^� No1CL . PHONE # 2P- 5(17-t 3 0 <br /> N CONTRACTOR ADDRESS �.c�� v C_.,6,p.t A CA LIC # -7 z 2(-C1 CLASS <br /> T J li <br /> R HAZARDOUS WASTE CERTIFIED YES NO-� WORK-COMP-4 WSA I / l r_L16 <br /> A iG <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 I BOARD OF EQUALIZATION # <br /> R ' <br /> illllll1111llillilill!!!!llll! <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- Z d>, Doo &AL '4U LA& WW t. _DATE� <br /> T 39- z I S ooh 4AdL. <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 11I1 <br /> P <br /> L APPROVED _ APPROVED WITH CONDITIONS) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> tlllllltt1111111lIlll Ilt 1!111 1111 11 1 ttit 1 1 1 t tl 11111 li Il 1!11111 i 1 1 !ltl11ltlil I !1 <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 /> c449vV a5 Aw,417SCT-APPLICANT'S SIGNATURE: ' TITLE I�*si� 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 thisresponsibilityfor the additional bitting by signature and date below. <br /> Name G f{�1/t��^i ( {1�'t7l1C�S C0• — � �IT �SI� <br /> Mailing Address 1• C2' 5aX 40" 5/44 t W 1MC*4 r G> 9 5 8:5 <br /> Day Phone Number DOW 1 2 - 4-�5w <br /> Signature Date f� <br /> EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) <br /> 4 <br />