Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR 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 1S 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-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE # <br /> F FAC I L I TY NAME ?A"' PHONE <br /> A <br /> C ADDRESS 1 L vjC <br /> 1 <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR 6 PHONE # <br /> Y k OR✓A c - ��3 -3 �fl � <br /> C CONTRACTOR NAME A c moi` <br /> !To c PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS by CA LIC # �'3 3(' CLASS 4 A Z C <br /> T1..,. - <br /> R HAZARDOUS WASTE CERTIFIED YES_ NO WORK.COMP.# �O0o c„W <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- ��wo x.45 R7 L-T DATE_ <br /> T 39: 0z C,ec.o <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39-- <br /> 39- <br /> P <br /> 9- <br /> 39- <br /> 39-P <br /> L APPRO)/HD APPROVED WITH CONDITIONS) DISAPPROVED i <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <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: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE-VORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATUFE: c1/; zTITLE Cal U DATE / J <br /> Indicate the responsible party to be billed for additional PHS-EHD 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_ - - C L;, kV O�hi� IN�. <br /> Mai L ing Address A ---2, AV,--- nni_SIDL CA qf,�C O <br /> Day Phone Numberc�C)C( <br /> Signature Date <br /> EH 23 008 ev 12/ /9 U Reg's May 5, 1994) <br /> 4 <br />