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05/04/2001 11:40 2095994249 <br />EP -c SITE a <br />F rACILITY NAME <br />C ADDRESS <br />T <br />L CROSS STR2E7 <br />;r <br />T I OWNER/OPERATOR <br />YI <br />rCCNTAACTOR NAME Mn - <br />0 <br />N 1 CONTRACTOR ADDRESS <br />f <br />R INSURER <br />A <br />C OTHER INFCRNATIOlt <br />0 <br />R <br />• <br />FLYING J <br />PRO,Tn'CT CONTACT 6 TELEPHONE *k <br />" (1®) <br />PHONE ■ <br />(. y 5s i "7 <br />PHONE m O� <br />j cars <br />WORK.COMP.A <br />I PHONE u <br />PHONE IF <br />ra(:t el <br />RM <br />�IilidliilllttIII lliilllt <br />TANX I <br />T,IK p ■ TANk SIZE CHEMICALS SACRED CURRE`iLY/PREVTOUS:Y PATS UST INSTALLED <br />39- <br />39- <br />N <br />9 -39- <br />N j 39- <br />39- <br />IL <br />i1tli�it ttiltttttlitttttlitlti itt Iii t titt <br />APPROVED ,/ APPROVED WITH CONDITIONS) DISAPPROVED t <br />A i (SEE ATTACHMtNT 'MITE{ CONDITIONS) <br />N i PLAN RCVTEwERS NAME_. <br />DATE <br />—ittitittttttllitttilitllttiltlll udd ilio r ff(iT1M iiiiltiliuttiiiiillitliitll�[- tt tt Ij <br />APPLICANT MUST PERPOILM ALL WORK IN ACCORDANCE NITS SAN J'OAOUIN COUNTY ORDINANC_S, STATE LAWS, AND RULES AND REGULATIONS OF ` <br />SAN JCACUIN COUNTY PUBL.*,C HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CSRTIFIES THE POLL.OWTVG: "I CERTIFY THAT :N <br />THE PERFORMANCE OF TH`E WORK FOR WHICH THIS P£RMIT IS ISSUED: I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME f <br />SUBJECT TO WORKER'S COMP—"SA CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATUZ CERTIFIES THE POLLOWING:� <br />•I CERTIFY THAT IN THE ORMANCE OF H� K F ICH THIS PERMIT IS ISSUED. I SHALL HMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF <br />el <br />APPLICANT'S SIGNATURE: TITLE J�Lk&rLjn lrDATE <br />Y � <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional PHS -ERV staff time expended beyond <br />permit payment coverage per tank. if the party designated below is different than the permit <br />applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br />by signature and date below. 'T,"or, y :rcr <br />CA aS6G <br />Name "� ►1 d e Is i hone number C.101i <br />Signature <br />EH 23-0036 <br />