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- «.�� ao•onnii rrcul� TO 18055462053 P.05 <br /> 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 IS SENT TO PHS-END REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PNS-EMD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE R PROJECT CONTACT E TELEPHONE R JEFF LEE @ E.D.A. 805-549-8658 <br /> F FACILITY NAME SAFEWAY FUEL CENTER PHONE N <br /> A 925-467-3840 <br /> C ADDRESS <br /> 1 <br /> L CROSS STREET <br /> l FONTANA <br /> T OWNER/OPERATOR PHONE N <br /> Y SAFEWAY, INC. 925-467-3840 <br /> C CONTRACTOR NAME T.B.D. PHONE N <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC tl CLASS <br /> 7 <br /> R HAZARDOUS WASTE CERTIFIED YES_ NO YORK.COMP.N <br /> A <br /> C FIRE DISTRICT T CITY OF STOCKTON PERMIT N <br /> 00-7702 <br /> 0 BOARD OF EQUALIZATION N <br /> R — — <br /> TANK ID R TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39• 20 000 GASOLINE 2/1/ObATE <br /> T 39m 10,000 10rnnn CAcOLINF �,LLOI <br /> A 39,• <br /> N 39- <br /> K 39- <br /> 39- <br /> 39� <br /> P <br /> 1 APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 11111111111111111111111111111111111111111111111111111111111111111111111111111 11111111111111 <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: "l CERTIFY THAT IN <br /> THE PERFORMANCE OF THE UORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT 10 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE- TITLE DATE <br /> Indicate: the responsible party to be bitted fnr additional PHS-ERD staff time expended beyond the M hour minimum installation <br /> payment.. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name_ NANCY VOVES, SAFEWAY, TNC- <br /> Mailing #ddress 5918 STONERIDGE MALL ROAD, PLEASANTON, CA 94558 <br /> Day Phone Number 25-467-38 0 <br /> S4gneture ` l� - Date Z Z 1 <br /> EM 23 DOB <br /> 4 <br />