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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS 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 TIME., ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # Ca L OdO 09.5 q?� PROJECT CONTACT b TELEPHONE # � (.tiE Lid & V61� <br /> F FACILITY NAME QUIk ST V�> �-fZ� PHONE # c116 <br /> C ADDRESS I�jb �(,� GDUlSE �4✓� A�/I�+- CSI- 5'3 6 <br /> I �f <br /> L CROSS STREET VNt Oh/ go, <br /> I <br /> T OWNER/OPERATOR PHON # <br /> Y QIK sree 4142,wS /Ne . 51c G,s-- - 8500 <br /> C CONTRACTOR NAME WAUT,o� &--r4(Yn1E2;1Z4W(T /�t/C. PHONE #(cf1(.) 3-)3 ^ll G% <br /> N CONTRACTOR ADDRESS e0 Boy- (a2$ VJ.5, p, gs(p-1 ' CA LIC Al 6( � 2�$ CLASS /� � <br /> T <br /> R HAZARDOUS WASTE CERTIFIED - YES V NOWORK.CDMP.#WN 665 'J z <br /> A <br /> C FIRE DISTRICT MA-�Er^ Fra. ' p6yr• 9Z-0w*ArOO .E �z°q 2�4 Pg-35 I PERMIT # <br /> T <br /> 0 BOARD OF EQUAL I ZAT I ON # �'� 44 — p($ (-?j <br /> R <br /> (I I I I I I I I I <br /> TANK 1111111 I l l l i l l l <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- 121' <br /> T 39- j 1 {2�Ooo U/✓L�14-0� �+�45 21N TE !qq$ <br /> 21 — 2 t2-,j 060 ti` n <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- ITT <br /> P <br /> L APPRO ED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( EE&ACHM�ENTWITHN PLAN REVIEWERS NAM DATE —S111111IIIII IIIIIIIII IIII lllilillllllllil <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN 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 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 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIF I ." <br /> APPLICANT'S SIGNATU E: -•� TITLE A4CI�f• MNC DATES <br /> k4K.7CF/ ? ' <br /> Indicate the responsible party to be billed for additional PHS-END staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name QV l K S-122 04,0-V-PEMS -, (tJL - <br /> Mailing Address P.o. aOxC S514-5 jC2.E)w r { CA q¢ <br /> Day Phone er <br /> Signatur Date <br /> EH 23 00 (Rev 1 % T Reg's May 5, 1994) <br />