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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ` APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATICN FCR 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-END UPON RECEIPT OF THIS LETTER. <br /> 00 NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE ;* (-4L- Opo Q s-j 1123 PROJECT CONTACT 8 TELEPHONE 4 1'I'IIY-E LEE "Croom e>JG/AJ62�1,J§, <br /> F FACILITY NAME QUID S'-CO? 57 PHONE clf ()?73-1168 <br /> A /� <br /> ADDRESS 1S� WE-ST 41AIIJ (WoiJ �)� RIPO�1� CA- x534,6 <br /> CROSS STREET _ A CA - Tom Qpp� <br /> I v <br /> T OWNER/OPERATOR PHONE <br /> Y Q�l1L sToP M�ZSt INC. I (Slob (v5�-— SSS <br /> C CONTRACTOR NAME wp,L-Cor) 6-rJ6,116SV-10J6SNC I PHONE (-f/(,) 3-73 - If68 <br /> 0 <br /> N CONTRACTOR ADDRESS q(jtox tp25IN. SL1G��N lA�uafs�[�f CA LIC $ 60- 7-3$ I CLASS yl� g �(/1-� <br /> T <br /> R HAZAROCUS WASTE CERTIFIED YES �� NO WORK.COMP.;*vVNc16(S�3 (oOZ <br /> A PERMIT 0 <br /> C FIRE DISTRICT V-1(26J F'LR-F 06fT. Zoal� q- '¢Z-� <br /> T <br /> 0 30ARD OF EQUALIZATION <br /> R <br /> i <br /> TAANKNK II11111i11111111111111111 <br /> ID TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATiCN: <br /> 39- or oxo V*L,eAyyo ATE SOI S <br /> T 39- t 2 -2 <br /> A 39- 1 2-5-"a DcT� •1 <br /> N 39- <br /> K 39- <br /> 39- <br /> Ilil � <br /> P <br /> L APPROVED 1C APPROVED WITH CONDITIONS) DISAPPROVED <br /> A ( TACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAMEQ4;5� DATE 7-/S 7 Iill11111111111111111111111111111111111 1 I I Illlliilillliil IIII111l11111111111111111111111 I1 1 111 I�I11111111 Illil <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:i <br /> "I CERTIFY THAT IN THE PERFORMANCE 0 HE WORK FOR WHI H THISP RMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S I <br /> COMPENSATION LAWS OF CALIFOR I ." <br /> APPLICANT'S SIGNATURE: TITLE �`�`• DATE <br /> H*CZt,d <br /> Indicate the responsible party to be billed for additional PHS-EHO 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 G?U IV— SZ'D09 n' zS .4 /n!C• c <br /> Mai L ing Address P.D. 607r- , 62-emw rr j CA- <br /> Day Phone Number (sto) �S 1 - BSaD <br /> Signature ay 5m\ Date 40 1� I� <br /> EH 23 008 3 UST Reg's M , 1994) <br /> 4 <br />