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FAC. 548 <br />fHEALTH DIVIS100,APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br />APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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 YEAR -- ONE TiME EXTENSION MAY BE GRANTED BY PHS-EitD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRiTE iN ANY SHADED AREAS. <br />Indicate the responsible party to be billed for additional PNS-E11O staff time expended beyond the 8 hour minimum instaltation payment <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name Tait & Associates <br />Mailing Address 1001 Galaxy Way, Ste. 404 Concord CA 94520 <br />Day Phone Number (5W680-6800 ZA510 8?8 FAX <br />SignatureDate 5/23/95 <br />T omas Schoenstei , Pr g ec Architect ' q� <br />EH 23 008 (Rev 1/7/92) WP <br />91 <br />EPA SITE # CAL 000028349 <br />PROJECT CONTACT & TELEPHONE # TaitS&hAssociateS 10 680-6800 <br />F <br />PHONE # 209 478-2723 <br />FACILITY NAME ARCO Facility 548 <br />A <br />C <br />ADDRESS <br />1612 Hammer <br />1 <br />L <br />— -- <br />CROSS STREET Brentwood Avenue <br />1 <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y I <br />ARCO Products Co. ATTN: Environ. Health & Safety <br />714 670-5300 <br />C <br />CONTRACTOR NAME <br />PHONE # <br />0 <br />N <br />CONTRACTOR ADDRESS <br />CA LiC # <br />CLASS <br />T <br />R <br />HAZARDOUS WASTE CERTIFIED YES NO <br />WORK.COMP.# <br />A <br />C <br />FiRE DISTRICT Stockton F.D. <br />PERMIT # <br />T <br />0 <br />BOARD OF EQUALIZATION # TK LiQ 44-000506 <br />R <br />111111111It11111111111111 <br />TAANKNK ID # TANK SIZE CHEMICALS 70 BE STORED PROPOSED INSTALLATION <br />39 DATE <br />�� <br />T <br />ae Gas o peStlmme <br />39- a OnS Oc n <br />A <br />39- 1 ga ons Sttmm„pr 9-5 <br />H <br />39 aa� ons 87 OctariGasoijne <br />K <br />39- 10 ,000 gallons 8 e Ga--&mmer <br />39- E!a eNSL21 I <br />39- <br />I T1 <br />P <br />L <br />APPROVED APPROVED WiTH CONDiTiON(S) DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME DATE <br />11111111111111111111111111111 IM11111IMMIIIIIIIIIIIII <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 <br />PERFORMANCE OF THE WORK FOR WHiCH THiS PERMIT iS ISSUED, i SHALL NOT EMPLOY ANY PERSON 1N 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 5/23/95 <br />Indicate the responsible party to be billed for additional PNS-E11O staff time expended beyond the 8 hour minimum instaltation payment <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name Tait & Associates <br />Mailing Address 1001 Galaxy Way, Ste. 404 Concord CA 94520 <br />Day Phone Number (5W680-6800 ZA510 8?8 FAX <br />SignatureDate 5/23/95 <br />T omas Schoenstei , Pr g ec Architect ' q� <br />EH 23 008 (Rev 1/7/92) WP <br />91 <br />