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0 . 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. C 0 N T R A C T 0 R CONTRACTOR NAME wAu o j 6—N&iA)EM4 &-4 I IC. CONTRACTOR ADDRESS eo VJ .56tra , ql 'j I PHONE CA LIC # 6t -�- -2--:5 'E> CLASS A - j3 HAZARDOUS WASTE CERTIFIED YES V NO I WORK.COMP.#wN9 665- 1!5 60 -2- FIRE FIRE DISTRICT M>R'Age=e,4, FIDE 9,9yZ 46tj V-$:�OOL6 CzDq Z-bi • s+3S PERMIT # BOARD OF EQUALIZATION # �'k N d, 44 - 0 1 G3 111111111111111111111111111111 TANK ID # 39- 121- 1 T 39- 121 — 2— A A 39- lam( -3 N 39- K 39- 39- 39- 1111 P L A N APPROVED TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION >o L1NL FDS G,qS S R -W TE lqq$ ITfTfITi1lTiTftTfTffffT fffflT _ APPROVED WITH CONDITIONS) DISAPPROVED (SEE ATTACHMENT WITH CONDITIONS) PLAN REVIEWERS NAME DATE Iill111111111111Iilllillliiitllltltlill IIIIII1111111111111111lI 11111111111111111111111 111111 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: "I 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 CALIF IA." APPLICANT'S SIGNATU E. TITLE �ClT• �� MNC DATE`O i Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum instatiation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name QV I IL S -IP P fty4le-y&7S , WC. L Mailing Address PO PJoX. 5--7+ CA 9¢53-- v � Day Phone "ber S(o Signa EH 23 =9641M Rev 1VU/95; 0NT Reg's May 5, 1994) :] Date EPA SITE # ChL OUp O+5 qZo PROJECT CONTACT $TELEPHONE # (AE #, W)q-raid &?L�A F FACILITY NAME QVIk 57AP NA4- PHONE # G116 373? -1166 6 A C pp ADDRESS 16 S% LQ(%(SE ll� 4e+ C-+/ � 6 I L CROSS STREET (>Nl ph/ go . I T Y OWNER/OPERATOR Quir- s Zee 11�A�2 lS, 1i✓c ' - PHON # S(o 6.s a- ` 8 Soo C 0 N T R A C T 0 R CONTRACTOR NAME wAu o j 6—N&iA)EM4 &-4 I IC. CONTRACTOR ADDRESS eo VJ .56tra , ql 'j I PHONE CA LIC # 6t -�- -2--:5 'E> CLASS A - j3 HAZARDOUS WASTE CERTIFIED YES V NO I WORK.COMP.#wN9 665- 1!5 60 -2- FIRE FIRE DISTRICT M>R'Age=e,4, FIDE 9,9yZ 46tj V-$:�OOL6 CzDq Z-bi • s+3S PERMIT # BOARD OF EQUALIZATION # �'k N d, 44 - 0 1 G3 111111111111111111111111111111 TANK ID # 39- 121- 1 T 39- 121 — 2— A A 39- lam( -3 N 39- K 39- 39- 39- 1111 P L A N APPROVED TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION >o L1NL FDS G,qS S R -W TE lqq$ ITfTfITi1lTiTftTfTffffT fffflT _ APPROVED WITH CONDITIONS) DISAPPROVED (SEE ATTACHMENT WITH CONDITIONS) PLAN REVIEWERS NAME DATE Iill111111111111Iilllillliiitllltltlill IIIIII1111111111111111lI 11111111111111111111111 111111 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: "I 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 CALIF IA." APPLICANT'S SIGNATU E. TITLE �ClT• �� MNC DATE`O i Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum instatiation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name QV I IL S -IP P fty4le-y&7S , WC. L Mailing Address PO PJoX. 5--7+ CA 9¢53-- v � Day Phone "ber S(o Signa EH 23 =9641M Rev 1VU/95; 0NT Reg's May 5, 1994) :] Date