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4 <br />ell <br />ENVIRONMENTAL HEALTH DIVISION <br />APP:LIC:ATHON FOR UNDERGROUND TANK INSTA� fLLATION PERMIT AteA/. <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 CALE)OAR YEAR IF A LEITER IS SENT TO PHS-jHD REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END, OF THE;CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION NAY BE GRANTED BY PHS -ENO UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE 0PROJECT CONTACT & TELEPHONE # ��>y v � L� LZ� S5't 5- 55� <br />CA 9 3u 2 i <br />PHOttE # CZ09�pQ — ($Zj <br />FACILITY NAME ���rt�.MPnf= i �J�-• <br />ADDRESS �� ►J . ftp-1r1rA�c- �-►J • �.FT <br />CROSS STREET <br />PHONE <br />OWNER/OPERAT# <br />OR 55 �5 <br />(,z0�ti q;,83 - . <br />CONTRACTOR NAME �{ �.L.Tp wG E tit 1 tat .�A-its PHONE <br />CONTRACTOR ADDRESS 134' (�ISb�G 1, ave r-. , W Zgs-�qI <br />CA LIC # c� l-"1 23 CLASS p. I j-,q� Mqj. <br />HAZARDOUS WASTE CERTIF�ED YES_, NO ; WORK.COMP.# d3c ZIZciz0(o6G9 <br />FIRE DISTRICT c. lT�. ply' l.- o4l PERMIT * � IA - <br />BOARD OF EQUALIZATION # � � w 40-Lj Cc C0 ® <br />tttIlllltt{lltlttIlltllltttit <br />tAN)t ID # TANK SIZE CHEMICALS TO BEISTORED PROPOSED INSTALLATION <br />4r1 I.. 3(1 AS' DATE <br />.39-l®4tA9 u AtM j <br />y K e.. L.UI 3l.. 1" 2T <br />39- _ !® ®e0 <br />39- <br />9-39- <br />39- <br />39- <br />39- <br />39- <br />39- <br />fill <br />APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED <br />p� TTACHMENT WITH CONDITIONS) DATE <br />PLAN REVIEWERS NAME Im HIM ttttl <br />1{11I{{1{Ilttttltlt{ <br />i <br />MUST PERFORM ALL WORK IN ACCORDANCE UITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />APPLICANT <br />SAN JOAQUIN COUNTY PUBLICS HEALTH SERVICES. CWNER OR LICENSED AGENT'S SIGNATURE CE TIFIES THE FOLLOWI23: HI :CERTIFY THAT IN <br />EMPLOY ANY PERSON IN SUCH A MANNER AS TO 8ECCuE <br />THE PERFORMANCE OF THE WORK FOR W ICH THIS PERMIT IS ISSUED, I SHALL NOT <br />WORKER'S COMPENSATION WS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB*TRACTiNG SIGNATURE' CERTIFIES THE FOLLOWING: <br />SUBJECT TO <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE W= FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CAL4FORNIA." <br />i <br />��--•• pp �� <br />SIGNATURE: e TITLE w� T�4i GATE <br />APPLICANT'S <br />ndicace the responsible party to be billed for additional PHS-EHO staff time expended beyond the 8 hour minimum instatlaton payment. <br />he party must acknowledge this responsibility for the additional billing by signature and date below. <br />_ame Jo fl VN C -1r C�U1srz�nnPti 1o.1G• > <br />;ailing Address 2s t.4. • IF: n ST , { I PrI P`o2O G(3 Z 3 0 <br />iay Phone Nunber oa - rj 83 - S -Y35- <br />Date <br />Signature ' `� - : ®\}y� _ Z-�y `--' <br />EH Z.3 003 (Rev 1/7192) "P <br />3 <br />