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FAC. 548 <br />ENVIRONMENTAL HEALTH DIVISION <br />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 PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PNS -END UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />Indicate the responsible party to be bitted for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br />The party must acknowledge this responsibility for the additional bitting by signature and date below. <br />Name Tait & Associates <br />Mailing Address 1001 Galaxy Way, Ste 404, Concord, CA 94520 <br />Day Phone Number <br />Signature <br />EH 23 008 (Rev 1/7/92) WP <br />Architect <br />3 <br />Date 5/23/95 <br />PROJECT CONTACT $ TELEPHONE # <br />EPA SITE #CAI, 000028349 <br />Taitom &hAssociateS 51 680-6800 <br />F <br />PHONE # 209 478-2723 <br />FACILITY NAME ARCO Facility 548 <br />A <br />C <br />ADDRESS <br />1612 Hamer Iane, Stockton., CA 95207 <br />I <br />L <br />— <br />CROSS STREET Brentwood Avenue <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <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 HQ 44-000506 <br />R <br />Ill!!llli{1111{lil{1{111 <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />TANK <br />39- DATE <br />-95 — <br />T <br />_ <br />39- Cra oris 2 Octan n 4 ttmmer ' <br />A <br />39-0 00-allons .-5 ._ qua - 95 — <br />N <br />39- a on Gasne <br />K <br />39- 10,00Q gglionsOct-; dSo iri Summer <br />39- <br />39- <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 />Itl!!illlt!lllllitll 111111 <br />APPLICANT <br />MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN <br />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 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 <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION <br />LAWS OF CALIFORNIA." <br />APPLICANT'S <br />SIGNATURE: TITLE DATE 5/23/95 <br />Indicate the responsible party to be bitted for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br />The party must acknowledge this responsibility for the additional bitting by signature and date below. <br />Name Tait & Associates <br />Mailing Address 1001 Galaxy Way, Ste 404, Concord, CA 94520 <br />Day Phone Number <br />Signature <br />EH 23 008 (Rev 1/7/92) WP <br />Architect <br />3 <br />Date 5/23/95 <br />