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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICAYIOM FOR INSTALLATION 00 UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH If HAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR if A LETTER IS SENT TO PNS-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-END UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. Sr\J©0 a 5 3l=z <br /> EPA SITE 0 PROJECT CONTACT A TELEPHONE 0 JEFF LEE @ E.D.A. 805-549-8658 <br /> F FACILITY NAME SAFEWAY FUEL CENTER PHONE 925-467-3840 <br /> A <br /> rryYTITq'Pv <br /> C ADDRESSIII <br /> 1 <br /> L CROSS STREET FONTANA <br /> 1 <br /> T OWNER/OPERATOR PHONE e <br /> Y SAFEWAYr INC. 925-467-3840 <br /> C CONTRACTOR NAME PHONE 0 <br /> o <br /> T.B. <br /> N CONTRACTOR ADDRESS CA LIC Y CLASS <br /> M- <br /> R <br /> TE CERT YES_ NO WORK.COMP.4 <br /> PERMIT CITY OF ST VC 11 — <br /> ALIZATION 0{{�{{{{{{{{{{{{{{K ID 0 + TANK SIZE ICALS TO BE STOREDION <br /> 39;- 20 000 t ASO INE 2/1/ObATE <br /> IT 39, ' 1 O OOO- 0 01 <br /> A 39:• <br /> W 39- <br /> K 39- <br /> 39, <br /> 39• <br /> Illiffffffniffifffffum <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME i 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 OIL LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERM17 IS ISSUED, 1 SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT 10 UORKERIS COMPENSATION LAOS OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> '•I CEF71FY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, t SHALL EMPLOY PERSONS SUBJECT TO UORKER'S <br /> COMPENSATION LAWS Of CALIFORNI p <br /> APPLI'CANT'S SIGNATURE: A� TIT LE'P¢ON. �l�Q. DATE 1 �� <br /> Indicate: the responsible to be billed for additional PHS-EHO staff time expended beyond the B hour minimum installation <br /> Payment.: The party must acknowtedge this responS(bility for the additional bitting by Signature and date below. <br /> Now NANCY VOVES SAFEWAY, TNN <br /> nailing Address 5918 STONERIDGE MALL ROADr PLEASANTON CA 94558 <br /> Day Pho ' Nmber 5-467-3840 F–� �A _� !�1 <br /> Sieneture G "- `� ��–"—\ Date vl <br /> EN Z3 009 (R TZ 13/ , ' ,eg May 5, 1994) <br /> 4 <br />