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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 EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # Geor e- 'Tnker4 ri <br /> F FACILITY NAME A v Te-I& S®n s y�C, PHONE # <br /> A <br /> C ADDRESS l Z O (=yolk Lj)eSt- Cf fcle <br /> I <br /> L CROSS STREET Fre-Ac(, Ccrnp P-®Qci <br /> I <br /> Y OWNER/OPERATOR A® Ie-ICherT c S 1 nC PHONE #q i Sulo-(o4''(0 <br /> C CONTRACTOR NAME A. �e l Gl l�rt Son,l,,L PHONE `#! (�3 (QG? <br /> 0 <br /> N CONTRACTOR ADDRESS p® so>c (S002- CA LIC # CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES NOS, WORK.CCIP.# <br /> A ' <br /> C FIRE DISTRICT Gin O-P c fr PERMIT # <br /> T <br /> 0 30ARD OF EQUALIZATION # <br /> R <br /> I l l l l l l l l i 11111111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- DATE <br /> T 39- 3SI ® haeScJ <br /> A 39- IS t7Q Un lea de nnh�r <br /> N 39- 2� o <br /> �, haste Dol Sea�fiember IR 4 <br /> K 39- <br /> 39- <br /> 39- <br /> Illi <br /> P <br /> L _ APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE L� <br /> 111111111111111111111 HIM11111MI1 1 111111111111111111111111 lIIIIIIIIIII iilR IM111 If IIIIIIIIIIIHIIIIIIIIIII III I If <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 /> APPLICANT'S SIGNATURE: TITLE Proje.clt Enc fo--ef' DATE S-11-q9 <br /> Indicate <br /> -II- <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name A. Te i&)e rt Sot), In G, <br /> Mailing Address PO &Dy- ISO(--)Z (::kCr0Me1)tL>, CA SSI <br /> Oay Phone Number q NO Ej 9 i( <br /> Signature 4- Date <br /> EH 23 008 (Rev 12/ /95, UST Reg's May 5, 1994) <br /> 4 <br />