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F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION P <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR ME�X[TX-NSION <br />T HAS BEEN ISSUED. <br />A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHSRHD THIS THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BVA& EV ISP CEIPT OF THIS LETTER. <br />1-1 1 jt:: lel -THt <br />EPA SITE #0(�j C�'3 2 "� PROJECT CONTACT & TELEPHONE # v <br />IN <br />FACILITY NAME �� lletc_LG`vr8.. a+k 6" 1 Cf l <br />ADDRESS 12l 0 (4c-4- iM <br />CROSS STREET <br />OWNER/OPERATOR <br />U VA - <br />CONTRACTOR NAME <br />CONTRACTOR ADDRESS O L_(•3 �,:s lC L CL! <br />HAZARDOUS WASTE CERTIFIED YES_ NO <br />FIRE DISTRICTfA-Q�'7,--j.. <br />BOARD OF EQUALIZATION # 4 <br />IIIIIII11111111II1111111111111 <br />TANK ID # <br />39- <br />3 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39 - <br />III <br />Ii -%L- I . <br />PHONE #-ejM- 47 1_ 3 1 1 1 <br />0 <br />PHONE # <br />?--c 11 , c <br />PHONE # t:nl l 6 . <br />7 <br />CA LIC # CLASS <br />i_ 61z3� <br />WORK. COMP . # W Iii <br />PERMIT # 1v <br />3 - `5,2-q <br />2-(G� <br />4!�-6S17 3b-0 <br />TANK SIZE CHE! ALS TO BE STORED PROPOSED INSTALLATION <br />/0, QO D re �A— , DATE <br />//), Od(i <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE �� G <br />1111111111111111111111111 111111111111111111111111 1111111111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII II IIII111111 <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 DATE <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 U L-A �C-t <br />Mailing Address � <br />r A cc, � <br />Day Phone Number C� <br />Signature Date -� C <br />EH 23 008 <br />( 12/13/9 ST Reg's May 5, <br />1994) <br />