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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. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. Theparty must acknowledge this responsibility for the additional billing by signature and date below. Name L! 6S 1= -A %L AM G� 709 W14 A/ Mailing Address 7 V? &/4J reI-t 1v 'i � A40de3 d 'CA , (n SJK Day Phone Number �G � � - 7 Signature / / M �V� Ja-'S- k&,;W4 Date U/ EH 23 008 (Rev /13/95, eg's May 5, 1994) El EPA SITE # CAczo 2-7-azz 9q PROJECT CONTACT & TELEPHONE # J�/� 1;I_ F FACILITY NAME OLk, CSZ� M�— PHONE # A C I ADDRESS ) -17, - - -.�- L CROSS STREET I T OWNE OPERATOR PHONE # Y As i,:� to 9 2 -6 C CONTRACTOR NAME cS'CvGp��1 •' PHONE #zor t N CONTRACTOR ADDRESS ��P � CA LIC # `3 �p.� CLASS tr6l A4 !`t c) T R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.#�'�� f A C FIRE DISTRICT S� PERMIT # T 0 BOARD OF EQUALIZATION # R 111111111111111111111111111111 TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION 39- SpLLi c- 2 fi I<-,- DATE T A 39- S 1' 2 _ "�� - :.. N 39 -E-A l NUMI - UNLEI�L� K 39- 39- 39- fiT P Iili L APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N Illllllllllillillllllllllilllllllllllililllllllilll PLAN REVIEWERS NAME DATE Illlllillilililllllllllllllllilllilllllllllllllllllllllllllllllllilllllll 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 PERFORMANCE OF THE WORK FOR WHICH H S PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPTFKAN CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE P E OF TN WOR X THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CAL �� APPLICANT'S SIGNATURE: `~ TITLE ,1E r.0 DATE "' Q Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. Theparty must acknowledge this responsibility for the additional billing by signature and date below. Name L! 6S 1= -A %L AM G� 709 W14 A/ Mailing Address 7 V? &/4J reI-t 1v 'i � A40de3 d 'CA , (n SJK Day Phone Number �G � � - 7 Signature / / M �V� Ja-'S- k&,;W4 Date U/ EH 23 008 (Rev /13/95, eg's May 5, 1994) El