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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS 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 TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. (7o7) EPA SITE # PROJECT CONTACT & TELEPHONE $ fAKK 165 146 F FACILITY NAME G PHONE A C ADDRESSEf,��mFs, � :?G I L CROSS STREET C;,L i I T OWNER/OPERATOR PHONE S Y C CONTRACTOR NAME 14dr PHONE S �L 0 N CONTRACTOR ADDRESS CA CIC S CLASS T R HAZARDOUS WASTE CERTIFIED YES No I WORK.COMP.9 A C FIRE DISTRICT PERMIT T 0 BOARD OF EQUALIZATION 1 R fllllllllllililllllilll11i1111 TANK ID S TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION 39- 2 C+ . AAL. X9 U L klz Q W L.EAOW _DATE T 39- S-`� 1 S ppO CTa,J�_ %j ffM N �— 12 A 39- N 39- K 39- 39- 39- 11111111111 fill I I liiiiiiiiiiiiiiiiiiiiillifillilI 1111111 P L APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE J� llill1111111I11ili11i I !li 11 li li 1 11 ! it I!! 1 1 Il!!t i !! it 1111 1ltl! 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: "1 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." APPLICANT'S SIGNATURE: J ' TITLE f I1�U�1' GT� 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 acknowledge this responsibility for the additional billing by signature and date below. Name CI-�L1/1�� aDtlC-'1 rj CO. I�?' �SK• Mailing Address F. C>1 Dal, foo I 945; 9:5 Day Phone Number (qW -1 2 /J w l f Q Signature Date EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994)