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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIO APPLICATION FOR UNDERGROUND STORAGE TANK INS ftw lifcu THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALHaV q IjILH CA IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS -END RED N T I NSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE j,AlhT,5�6,Y.. #MUP+ONURECEIPT ��OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. ��j�4E4B�1MIjT/S RVIrlP;�q I Indicate the responsible party to be billed for additional PHS-EHO 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 ctrli%,vF-0w PFLOVtAcr-5 Co, 'e1zMlT D�S� _. t Ma i L i ng Address p a - ( X 00 1Nm O 1� Ct, 9458-�> Day Phone Number - S ( O — 'j�_) o'2 / I -TC-/ Signature l - EH 23 008 (Rev 12/1 UST Reg's May 5, 1994) Date lo/ of f EPA SITE # (�AL_ OCCO PROJECT CONTACT & TELEPHONE # %44A- '^_- FFACILITY NAME GH P -%/P4 ) S' s ' Gi - C- I'l I PHONE # er'��1- - 4 I►5 A IADDRESS & CD *3 ! �� C/. - �1iFi �J•%]C�^Mv1" - L CROSS STREET �sEN a JA0L.-r i7R-,' I YOWNER/OPERATOR 7luk e �Aa,�s PHONE # 'i.09- �-"�� •51�.4•�I C CONTRACTOR NAME i�Ci�p ' C�h(�F�y'rf12�JG��j PHONE N T CONTRACTOR ADDRESS f7p� �L(Q3 Cpl 9&5 CA LIC # 5�(0 C;Q I CLASS I R HAZARDOUS WASTE CERTIFIED YES ✓ NO WORK.COMP.» (^jGl j'S (LI.ODp A C FIRE DISTRICT CJTOCAC-1—owPERMIT # 7 0 BOARD OF EQUALIZATION # R 1111111 ! 111111111111111 ! 111111 TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION 39-_rl t.. O .coo (� E 1 G U « DATE T 39- r 5 u a �7 A 39- S lt_ N 39- K 39- 39- 39- ITTTTtT>TIT i 1TITlTtTtT(I�TI-i-t-1-1-rr P 111 i L APPROVED PPROVED WITH CONDITION(S) DISAPPROVED A N SEE AACHMENT WITH CONDITIONS) PLAN REVIEWERS NAME Oli% (� t,��L�✓ 1itllllliillilt1111111111111 i II ISI 111 llllillllUllllllltti111111111i111111l11111i11t11111i111 DATE I II I II11111lII111 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 CALIFORNIA." APPLICANT'S SIGNATURE: �. sv TITLE FRQ,. MC3EZ DATE Indicate the responsible party to be billed for additional PHS-EHO 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 ctrli%,vF-0w PFLOVtAcr-5 Co, 'e1zMlT D�S� _. t Ma i L i ng Address p a - ( X 00 1Nm O 1� Ct, 9458-�> Day Phone Number - S ( O — 'j�_) o'2 / I -TC-/ Signature l - EH 23 008 (Rev 12/1 UST Reg's May 5, 1994) Date lo/ of f