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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 ENO OF THE CALENDAR YEAR. A ONE YEAR -- ONE TINE EXTENSION MAY BE GRANTED BY PHS-EHO UPON RECEIPT OF THIS LETTER 00 NOT WRITE IN ANY SHADED AREAS. 39 - III - -------------------------.........---•---...............,........ DATE dA PLAN REVIEWERS NAME APP D APPROVED WITH CONDITION(S) _ DISAPPROVED (SATTACHMENT WITH CONDITIONS) 1111111lI1I11111111f !!illi 111111 1 it 11ii11111 flfi 1 I ill Ilil i fllllli 1 II t 1! lllllllilll; • 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 PERFORMANC_ OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANT 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 P NCE OF 'NE WO WHICH THIS PERM COMPENSATION LAWS OF CA IT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S IFORNIA-" APPLICANT'S SIGNATURE: 1 TITLE<- JK t`%1�f�7�tiATE r—� dicate the responsible party to be billed for additional PNS --HD staff time expended beyond the 8 hour minimum installation payment. e party must acknowledge this responsibility for the additional billing by signature and date below. me ��- 1 L — C� /1IRW IiI EIi�an T 0.,gUM i L i ng Address f �� % y 01, �1+ '� 2,t / eJ}�9 • y Phone Number 6)4+g ;nature C,Gl�X �/�-s� nl Ak— F 23 008 (Rev 1/7/92) WP / —S � &,,, EPA SITE I PROJECT CONTACT & TELEPHONE F FACILITY NAME tw7-X X Ori PHONE » A I I ADDRESS 2 D7 CLU L I I CROSS STREET I Y I OWNER/CPERA70R � G� t,l `i. w1, �V M PHQNE » q! tV -4�3-0�� C I CONTRACTOR NAME 0T� PHONE '1 NI CONTRACTOR ADDRESS T+3 rz,,,� j.,r- SAX lr2'; f � I CA LIC » � `� � .� . CLASS R HAZAROCUS WASTE CERTIFIED YES NO K.CCMP.» A C I, FIRE OISTRICT I PERMIT a I BOARD OF EQUALIZATION » / /Y -03 6 06/ (lililillfl11111)11l1i11111111! TANK ID » TANK SIZE 39- cc 1 1 Z, C e C CHEMICALS TO BE STORka IZ!✓ (<,� 1��-� i� i e ;� �� PROPOSED INSTALLATION DATE A 39- N 39- K 39- 39- 39 - III - -------------------------.........---•---...............,........ DATE dA PLAN REVIEWERS NAME APP D APPROVED WITH CONDITION(S) _ DISAPPROVED (SATTACHMENT WITH CONDITIONS) 1111111lI1I11111111f !!illi 111111 1 it 11ii11111 flfi 1 I ill Ilil i fllllli 1 II t 1! lllllllilll; • 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 PERFORMANC_ OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANT 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 P NCE OF 'NE WO WHICH THIS PERM COMPENSATION LAWS OF CA IT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S IFORNIA-" APPLICANT'S SIGNATURE: 1 TITLE<- JK t`%1�f�7�tiATE r—� dicate the responsible party to be billed for additional PNS --HD staff time expended beyond the 8 hour minimum installation payment. e party must acknowledge this responsibility for the additional billing by signature and date below. me ��- 1 L — C� /1IRW IiI EIi�an T 0.,gUM i L i ng Address f �� % y 01, �1+ '� 2,t / eJ}�9 • y Phone Number 6)4+g ;nature C,Gl�X �/�-s� nl Ak— F 23 008 (Rev 1/7/92) WP / —S � &,,,