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F <br />A <br />C <br />I <br />L <br />T <br />C <br />T <br />T <br />10,-t16-1996 3:32PM FROM RML PETALUMA 76S683S P.2 <br />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 15 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 PNS -END 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 -FMD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE ig CAL000029680 PROJECT CONTACT. & TELEPHONE oshar'yn Mitchell/Craig Schafer (707) 7 : <br />FACILITY NAME LINCOLN VILLAGE WEST CHEVRON• <br />ADDRESS 2905 WEST BENJAMTN HOLT DRIVE, STOCKTON, CALIFORNIA 95207 <br />CROSS STREET PLYMOUTH ROAD <br />u4xERIOPERATOR CH EVRON PRODUCTS, INC. <br />m.• 1 (510) 842-950* <br />CUNTRACIOR NAME BLEVIN'S CONSTRUCTION/John Savidge, Jr.__.! <br />lonja Court <br />�ille. California 95667 <br />HAZARDOUS '.'AS7E CERTIFIED its- X No ETA <br />FIRE DISTRICT Stockton PERMIT 9 <br />,G RD OF EQUALIZATICH 2 44-031913 <br />of ivy MfTm <br />APPROVED APPROVED WITH CONDITICN(S) DISAPPROVED <br />(SEE ATTACHMENT WITH CONDITIONS) <br />PLAN REVIEWERS NAME DATE <br />APPLICANT MUST PERFORM ALL WORK ;N ACCCRDANCE 'JI7N SAN JCA*UIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN jCACUIN COUNTY PV3LIC HEALTH SERVICES. 7-;KER OR L!CINSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS Pr;MIT ;S ISSUED, I STALL NOT EMPLOY ANT PERSCH IN SUCH A MANNER AS TO 3ECOME <br />SJOIECT TO WCRKER'S CCMPENSATION LAWS CF CAL;FCRN]A.'* CONTRACTCR's HIRING CR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLCWING: <br />"I CERTIFY THAT IN THE PERFORMANCE CF THE IJC2K FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />C;;!1ipENSA71ON LAWS OF CALIFORNIA -0 <br />AFPL!CANj,s SIGNAIUA <br />ert H. Lee & Assoc- TITLE Jj2b_Cam AjUDATE 10L16j96_ <br />:nzicaze the responsible party tl be bitted f:r E=ditiona( 7h5 -z,0 stafi time expended beyond zhe 8 hour mini,-gAn insrat laxion <br />Pz,Y.-,e1T. The parry mast ackncwledge this res;:,cts:zi(iEy for *!:e addi;ionaj bittir;S by signaz%;re and date beLow- <br />N2 w Robert H. Lee & Assoc., Inc. ... Attn! Sharyn Mitchell <br />Rai I ing Address 1137 North McDowell Boulevard, Petaluma, California 94954 <br />Day Phcne Number- (Z97 L- 765-1660 <br />twn 4 <br />=m 23 003 (Rev 12/13/95, 7 %eg,/sxm:7 S, Li <br />4 <br />MINt, <br />m <br />