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SAN SAN JOAQUIN COUNTY PUBLIC HEALTH *SERVICES ENVIRONMENTAL HEALTH DIVISIAPPLICATION FOR UNDERGROUND STORAGE TANK INftFINTHE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR Q{�j I If„�jItCH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PMS - N T41 S( fb NSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTEENSION MAY BE P4,?N§- PON RECEIPT OF THIS LETTER. APPLICANT MUST PERFORM ALL WORK IN /ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH VICES. OWNER OR LICENSEED 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 CALIFORNIA." APPLICANT'S SIGNATURE: TITLE I'Rol. MUfz DATE Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name c{Hf,VFoW PFL0VtAGTS Co. F7F-rzMt7 DI-sK.. I I' > co oo � Cts 94583 - Mai l ing Address p � ijOX 4 t �`N ��o Oay Phone Number 5 FO �2 ! Signature - ?4� i�i Date EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) - ALHEALTH DO NOT WRITE IN ANY SHADED AREAS. 4RM1T/SLERV EPA SITE # CAL� 0=0 PROJECT CONTACT & TELEPHONE # F FACILITY NAME GH E�Ft�N S• S • 4r- G t "3 I PHONE # A C I ADDRESS �.� ¢�?) I ��i/. _ �llEii �j•{C)C.�^�•N - L I CROSS STREET &e_N . JA our t2F�' YOWNER/OPERATOR uA �� PHONE # 'Log,- +146 - 1541 '-7 C CONTRACTOR NAME Lf SQ C;> CptiI jZUG-n PHONE # 0 N CONTRACTOR ADDRESS PO& t�3 I cjg' CA LIC # 50(0 ! CLASS 18� CIO T R HAZARDOUS WASTE CERTIFIED YES ✓ NO WORK.COMP.r (,�jQ'rs(c{-pOp( A C FIRE DISTRICT $TOc\crow PERMIT # T 0 BOARD OF EQUALIZATION # R 11111111111111II111111111l1I1i TANK ID # T I SI CHEMICALS TO BE STORED PROPOSED INSTALLATION 39- 1 +, kQ SU a jV DATE T 39- 15 U M �/ A 39- •' jt-iL •'417 N 39- _ K 39- 39- i 39- 1111 I rrTM171TIPfT1111 j 11 P L AP RO APPROVED WITH CONDITION(S) _ DISAPPROVED A ( _ (S TTACHM£NT WITH CONDITIONS) A o N PLAN REVIEWERS NAME /��(((, {` DATE 1IIIIIIIIIIIIIIIIII11 I 1 I 11 fl11111! H 11 I 111IIII I IIIIIIIIIIIIIIIIIIIIIIIIIIIII!llll1IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII11 111111111 APPLICANT MUST PERFORM ALL WORK IN /ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH VICES. OWNER OR LICENSEED 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 CALIFORNIA." APPLICANT'S SIGNATURE: TITLE I'Rol. MUfz DATE Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name c{Hf,VFoW PFL0VtAGTS Co. F7F-rzMt7 DI-sK.. I I' > co oo � Cts 94583 - Mai l ing Address p � ijOX 4 t �`N ��o Oay Phone Number 5 FO �2 ! Signature - ?4� i�i Date EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994)