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9 9 FAC. 548 ENVIRONMENTAL HEALTH DIVISION 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 END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. I""'I"'111f'11"1"1jt1t" TANK ID # 39- 3 39- A 39- N 39- K 39- 39- 39- '1'I PROJECT CONTACT & TELEPHONE # VN: imviron. Health & 5c' YES NO .D. HQ 44-000506 TANK SIZE daa—^_ llons -10 000 a ons cfalions CA LIC # PHONE # ( 209 ) 4 PHONE # X714 670-5: PHONE # —CLASS WORKWORK.COMP.### PERMIT # CHEMICALS TO BE STORED P L APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE (litiillllilillllltl iiiiil� PROPOSED INSTALLATION 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 THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE DATE 5/23/95 Indicate the responsible party to be billed for additional PNS-EHD staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name Tait & Associates Malting Address 1 UU I L Day Phone Number 5 Signature T oma; EH 23 008 (Rev 1/7/92) WP 3 Date 5/23/95 EPA SITE # CAL 000 F FACILITY NAME ARCO Fa A C ADDRESS 1612 Hamm I L CROSS STREET Brentwo I T OWNER/OPERATOR Y ARCO Products Co. C CONTRACTOR NAME 0 N CONTRACTOR ADDRESS T R HAZARDOUS WASTE CERTIFIED A C FIRE DISTRICT Stocktc T 0 BOARD OF EQUALIZATION # R I""'I"'111f'11"1"1jt1t" TANK ID # 39- 3 39- A 39- N 39- K 39- 39- 39- '1'I PROJECT CONTACT & TELEPHONE # VN: imviron. Health & 5c' YES NO .D. HQ 44-000506 TANK SIZE daa—^_ llons -10 000 a ons cfalions CA LIC # PHONE # ( 209 ) 4 PHONE # X714 670-5: PHONE # —CLASS WORKWORK.COMP.### PERMIT # CHEMICALS TO BE STORED P L APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE (litiillllilillllltl iiiiil� PROPOSED INSTALLATION 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 THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE DATE 5/23/95 Indicate the responsible party to be billed for additional PNS-EHD staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name Tait & Associates Malting Address 1 UU I L Day Phone Number 5 Signature T oma; EH 23 008 (Rev 1/7/92) WP 3 Date 5/23/95