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F A C I L I T Y 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. EPA SITE I PROJECT CONTACT 8 TELEPHONE + MIKE Leff- -FACILITY NAME GANa'PA'5 C (�,(j A��-{-� PHONE ADDRESS L�.2 aAAj / t(T Yp", `MT7 , SGA CROSS STREET OWNER/OPERATOR dem o J _ ��4W &P r,\ C CONTRACTOR NAME 0 ' N CONTRACTOR ADDRESS Q, lj, f3O X 140',j T R HAZARDOUS WASTE CERTIFIED A' C I FIRE DISTRICT C 1" T ' 1 0 30ARD OF EQUALIZATION I R PHONE ;* 200) - 1!�+3 - i C73(0 PHONE CC:) - C ;+ B, 3 j O CA LIC A 3230 cuss A,B,HAe,++Ic, C-1 0 TES V NO ty (t -j--) Hct ++ WORK. CCMP. f -�L) PERMIT �Iy F'ROGr� 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: "1 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 CALIFORNI " ' rl APPLICANT'S SIGNATURE: �� 1G`` - 7 �C - TITLE /'t.-2.o.c sig DATE /,Ii -.27 6O Indicate the responsible party to be billed for additional PHS-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 (i+L4N�P V C>d,I''L N/A --ii Mailing Address' J v+� !�1 t ��T lW`^-• :� 1�4 }4 "-' o" ' Day Phone ,Number A-05 — C)+5 -- I G Signature 'CIL, ( EH 23 008 (Rev 12/13/95, UST Reg's y 5, 1994) Date /.2-,17-46 111111111111111111111111111111 TANK ID 39-0002311,04500 49 TANK SIZE 000 CHEMICALS TO BE STORED UI.ILD, SUP. G>A-. PAQPACSF7 INSTALLA;FFBN DATE T 39- itt Vz 000 U(v;-C). Rea,, C, AM —Fc—s-- 14? — A 39 1% • O 5 000 I i u I '1 �_ N 39- �► .O h tODO p1S.L_ ,�- �- K 39- — j 39- -- 1111 PLAN I111flllllllllilllilllllii � REVIEWERS NAME94-46, I III111I1! j APPROVED APPROVED WITH CONOITION(S) ATTACHMENT WITH CONDITIONS) C I I11 II ll II IIIIIIII11I11111111111111t1i11111111111111111111111 j DISAPPROVED 6a C, DATE 1111111111111111 P L ASEE N 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: "1 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 CALIFORNI " ' rl APPLICANT'S SIGNATURE: �� 1G`` - 7 �C - TITLE /'t.-2.o.c sig DATE /,Ii -.27 6O Indicate the responsible party to be billed for additional PHS-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 (i+L4N�P V C>d,I''L N/A --ii Mailing Address' J v+� !�1 t ��T lW`^-• :� 1�4 }4 "-' o" ' Day Phone ,Number A-05 — C)+5 -- I G Signature 'CIL, ( EH 23 008 (Rev 12/13/95, UST Reg's y 5, 1994) Date /.2-,17-46