COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK i INSTALLATION PERMIT �, V APPLICATION FOR INSTALLATION OF PNDERGROt;3Np TANKS ARE ONLY VALID FOR THE CALENDARIYEAR IN WHICH IT HAS BEEN ISSUED - A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS -ORD REQUESTING THIS EXTENSI.N TkIRTY DAYS PRIOR TO THE END' OF THE;CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT SOF THIS LETTER. I DO NOT WRITE IN ANY SHADED AREAS. 'iIIIi11111611111111111H1errraaaago aeta was ase■ee+.+•-- - - i APPLICANT MUST PERFORM ALL WORK IN ACCORowe WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLICS HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE C"TIFIES THE FOLLOWING: "I'CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR W .ICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY AN, PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB*TRACTtNG SIGNATURE' CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WCBK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALI1FORNIA."' APPLICANT'S SIGNATURE: TITLE 1�� K 4 ■ DATE _ Indicate the responsible partY to be billed for additional PHS -END Staff time expended. beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional bitting by signature and date below. Name _jo a Vn. SIT Cl�cs�nta�. Frac • � Maiting Address 52S •-Tc{iRt� sl- Day T Day Phone Number � Signature EH Z3 008 (Rev 1/7/92) WP 2c,q- tj$3- s 3 Ck C - Date 1 EPA SITE 0 C L,9 _:�> 0 I PROJECT CONTACT & TELEPHONE L 20' `� 3 � SS 3e) PHONE # c > — I F FACILITY NAME �V-tF �t�nf= , ��1L A C ADDRESS N. i I L CROSS STREET I ' T OWNER/OPERATOR I PHONE # ZOa) rv- &.7, —'&C:3 Y C; CONTRACTOR NAME (�.t-Tp tJ E-t�J I-% 1 t.��l.1f�► ; PHONE #�� I (p MAT— —♦ aB 8 N CONTRACTOR ADDRESS gi3 �{ R �s►�c C, l.av�c. , -C t LIC # (l, l-� 23$ CLASS T. YES, NO WORK.CMP.# Lilo Zt LCAZ-0(006 7 P, NAZgRDOIIS WASTE CERTIFIED I A'. C; FIRE DISTRICT e-t'Tm, 0E-o®cJ�Z IT #; TQI BOARD OF EQUALIZATION %L ®-i (p:0® R. I tittttttttittttttitltit�tttitl TANK 1D # I TAMC 18E CHEMICALS TO BEISTORED PROPOSED INSTALLATION S AtM Le kA L.. 3/I ( AS' DATE 34- l® tatK �' I � S T 39- Eaa�soudlG Su►PQQ.- s/� qs- A 39- ap_e%� - x 39- K 39- 39- , - ttttt� I APPROVED APPROVED WITH CONDITION(S) s ffffffffffflumm DISAPPROVED rA39 ®® TTACHMENT WITH CONDITIONS) PATE PLAN REVIEWERS NAME Itttt • ■frerffffflfftfl lfi/ - 'iIIIi11111611111111111H1errraaaago aeta was ase■ee+.+•-- - - i APPLICANT MUST PERFORM ALL WORK IN ACCORowe WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLICS HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE C"TIFIES THE FOLLOWING: "I'CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR W .ICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY AN, PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB*TRACTtNG SIGNATURE' CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WCBK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALI1FORNIA."' APPLICANT'S SIGNATURE: TITLE 1�� K 4 ■ DATE _ Indicate the responsible partY to be billed for additional PHS -END Staff time expended. beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional bitting by signature and date below. Name _jo a Vn. SIT Cl�cs�nta�. Frac • � Maiting Address 52S •-Tc{iRt� sl- Day T Day Phone Number � Signature EH Z3 008 (Rev 1/7/92) WP 2c,q- tj$3- s 3 Ck C - Date 1