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'Am ENt�mc-- <br />j SAN JOAQUIN COUNTY PUBLIC HEALTH SERV CES <br />ENVIRONMENTAL HEALTH DIVISION SEP 04:1996 <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMTT� <br />ENVIRON 7M7ENFETpRA�`y/L,,1�cIEESL[Yi <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENCIA�i R X'1 M7 & 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 TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPOt RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />Indicate the responsible party to be billed f r additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this re(lonsibility for the additional billingbysignature and date below. <br />Name -L/7 %" V4F— *-Q'/ZUC�� <br />Mailing Address P. o • Sox 5 -9 -cls- FnrmonZ Ca, FYS-3 ''- <br />Day Phone Number <br />Signa <br />EH 23 <br />s May 5, 1994) <br />M <br />Y <br />Date <br />EPA SITE # C A 000 <br />3 3 38 <br />PROJECT CONTACT & TELEPHONE # m//eC C 3 3 _-///8 <br />F <br />A.7o9)511'8 <br />FACILITY NAME S <br />O # o? d <br />PHONE <br />`. -71Y,9 <br />1 <br />ADDRESS 93-21 <br />5i o2 b <br />L <br />CROSS STREETJ <br />I <br />D a <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />C <br />0 <br />CONTRACTOR NAME <br />%Li n h C <br />PHONE # 9 ,�S D <br />N <br />CONTRACTOR ADDRESS P• 0 R>O X. <br />S CA L I C# <br />CLASS <br />T <br />V G CCc 6 a oZ <br />R <br />A <br />HAZARDOUS WASTE CERTIFIED <br />YESLX NO I <br />WORK.COMP.#NSG _ _ 0 O <br />C <br />T <br />FIRE DISTRICTc /- y 6 F <br />5-749,44,) — F, -^e 4 L1 d I <br />PERMIT # <br />0 <br />BOARD OF EQUALIZATION <br />O <br />NK ID # <br />T9 <br />y\T <br />TANK SIZE C MICALS TO BE STORES PROPOSED INSTALLATION <br />7C <br />v &, t di DATE /99 <br />< <br />- <br />N <br />39- <br />K <br />9- <br />39- <br />39- <br />39-39- <br />39- <br />P <br />111111111111111111[111rl <br />L <br />APPROVED APPROVE WITH CONDITION(S) DISAPPROVED <br />N <br />PLAN REVIEWERS NAME <br />(SEE ATTACH ENT WITH CONOI7IONS) <br />L% <br />tllliiilltltillltilllll itillliliillll <br />GATE <br />!lltiilll1t111 tililtlitllili ilililillll111111!!ilitll!]lilll!!!l11111lIlIIl1lllitll <br />APPLICANT <br />MUST PERFORM ALL WORK IN ACCORDANCE WITH S 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNI ." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERf.ORMAN <br />0 THE WORK FO WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALI0 NIA. <br />APPLICANT'S SIGNATU E: <br />TITLE rn A - GATE Ar'4j C--4? fO <br />Ci3 , <br />Indicate the responsible party to be billed f r additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this re(lonsibility for the additional billingbysignature and date below. <br />Name -L/7 %" V4F— *-Q'/ZUC�� <br />Mailing Address P. o • Sox 5 -9 -cls- FnrmonZ Ca, FYS-3 ''- <br />Day Phone Number <br />Signa <br />EH 23 <br />s May 5, 1994) <br />M <br />Y <br />Date <br />