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MAY -26-1994 16:0? FROM TO 912094640139 P.04 <br />! i <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br />APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR Ill WHICH IT HAS BEEN ISSUED. <br />A PERMIT MAY BE EXTENDER INTO THE NEXT CALENDAR YEAR IF A LETTER I5 SENT TO PNS -END REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE T114E EXTENSION RAY BE GRANTED BY PHS -iib! UPON RECEIPT OF THIS LETTER. <br />Do NOT WRITE IN ANY SHADED AREAS. <br />P <br />L _� APPROVED APPROVED WITH CONDITIONCS3 _� DISAPPROVED <br />A TS—EEATTACHMENTWITH CONDITIONS) DATE <br />N PLAN REVIEWERS NAME 111111IR1111IMMIll III 111i I <br />1111t11t111t1111111111111111 Jill litmll 11 Ull 11111111 Ifflill III III <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN jDMIN THE PERFORMANCE OF THELIA FORMWHIICCHITHIS PERMIT S. OWNER IS IS5[�, I SHALL NOT EMPLOY ANYCENSED AGENT'S SIGNATURE TIFIES PERSONTHE N SUCH AIMANNERIAS To BECOME IN <br />aI JCERTIFY T INSTHHEMPER�FORMANCE OF TTHETION LAWS OF �WORK FOR WNiCHK T IS�PERMIToRaS NISENG OR ISSUEDSUI SHALL <br />TING EEW�IGNATURE PERSONS SUBJECTETOTHE WORKERISiiNfi: <br />COMPENSATION LAWS Of CALIFORNIAf� <br />APPLICANT'S SIGNATURE: <br />TITLE DATE <br />indicate the responsible party to be bil ed for additional PHS-EAD staff time expended beyond <br />the $ hour miniwus installation psyment. <br />The party must wianowledge this responsibility for the additional billing by signature and date below. <br />Naiee � <br />Matting Addressy,-ZO WjggS f !ZTa 0 1321 <br />DayPhony !lumber <br />Signature il% <br />EH 23 008 (Rev 1/7M) W' <br />3 <br />Date <br />EPA SITE <br />PROJECT CONTACT & TELEPHONE #yoLL <br />&g1�157� <br />PHONE # NO T�iG}+S� 6T <br />F <br />FACILITY NAME FIs,,,; -+f j �.4 i' IAC L1.�./t i... �'L.b �• <br />A <br />C <br />ADDRESS <br />u <br />I <br />L <br />CROSS STREET <br />I <br />T <br />OWHER/OPERATOR <br />�t.-�t; we'? <br />t G . <br />PHONE # <br />��� -73-f <br />Y <br />c <br />CONTRACTOR INANE <br />oW a wL <br />PHONE # 9kko -- 3°� L• 1 g (c0 <br />0 <br />N <br />CONTRACTOR ADDRESS ��--I p <br />G� e. ►cn. CA LIC # <br />�3g112. cusp t�1 c3� cc,c L�t�E <br />T <br />YES NO <br />ONP <br />WORK.0.# W GG' gOS1 y� <br />R <br />HAZARDOUS WASTE CERTIFIED <br />C <br />FIRE OESTRICT t r <br />or- 1;;;(��A,,[ <br />PERMIT # <br />T <br />0 <br />BOARD OF EQUALIZATION if <br />R <br />11I t11111t11111t1tl111111tt111 <br />TANK ID #N <br />TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- _ �/�� <br />oo frf.t.�_1� <br />r1...:t vc <br />t-• ATE <br />r_ t-. ^1�Y <br />T <br />A] <br />9- <br />39- <br />�. <br />- – d�� 1'. r t �s' <br />N <br />34- <br />K <br />39- <br />39- <br />111E <br />P <br />L _� APPROVED APPROVED WITH CONDITIONCS3 _� DISAPPROVED <br />A TS—EEATTACHMENTWITH CONDITIONS) DATE <br />N PLAN REVIEWERS NAME 111111IR1111IMMIll III 111i I <br />1111t11t111t1111111111111111 Jill litmll 11 Ull 11111111 Ifflill III III <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN jDMIN THE PERFORMANCE OF THELIA FORMWHIICCHITHIS PERMIT S. OWNER IS IS5[�, I SHALL NOT EMPLOY ANYCENSED AGENT'S SIGNATURE TIFIES PERSONTHE N SUCH AIMANNERIAS To BECOME IN <br />aI JCERTIFY T INSTHHEMPER�FORMANCE OF TTHETION LAWS OF �WORK FOR WNiCHK T IS�PERMIToRaS NISENG OR ISSUEDSUI SHALL <br />TING EEW�IGNATURE PERSONS SUBJECTETOTHE WORKERISiiNfi: <br />COMPENSATION LAWS Of CALIFORNIAf� <br />APPLICANT'S SIGNATURE: <br />TITLE DATE <br />indicate the responsible party to be bil ed for additional PHS-EAD staff time expended beyond <br />the $ hour miniwus installation psyment. <br />The party must wianowledge this responsibility for the additional billing by signature and date below. <br />Naiee � <br />Matting Addressy,-ZO WjggS f !ZTa 0 1321 <br />DayPhony !lumber <br />Signature il% <br />EH 23 008 (Rev 1/7M) W' <br />3 <br />Date <br />