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Vl CG CVVl 1V VVIII rRV1I •+ <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 PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE N PROJECT CONTACT It TELEPHONE 0 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 2R08 COUNTRY CLUB <br /> I <br /> L CROSS STREET FONTANA <br /> 1 <br /> T OWNER/OPERATOR PHONE A' <br /> Y SAFEWAY, INC. 925-467-3840 <br /> C CONTRACTOR NAMET B D PHONE B <br /> O <br /> N CONTRACTOR ADDRESS CA LIC M CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES NO_ YORK.COMP.# <br /> A <br /> C FIRE DISTRICT CITY OF STOCKTON PERMIT / — <br /> T <br /> 0 BOARD OF EQUALIZATION R <br /> R <br /> 1111111111 <br /> TANK 111111111111111 <br /> TANK ID N TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLAT IDN <br /> 39- 20 000 GASOLINE ,2/1/ObATE <br /> FT 39� �0_:O.00 1(11 non <br /> 'A 39. <br /> N 39- <br /> K 39- <br /> 39= <br /> P <br /> Im IiiIIATi ITTIfilT17ITTTIITiiiiTT1 <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> illilliliillllllllll � 1111111111111111 IIIIIIIIIIIIIIIilllli Ililillllllill <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAYS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE UORK FOR WHICH THIS PERMIT IS ISSUED, 1 SMALL 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 /> '•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 LAYS OF CALIFORN{ p <br /> APPLICANT'S SIGNATURE: �� TI T LE ' 'VCL*N ��Q. DATE 3 1 01 <br /> Indicate. the responsible 4.Wc. be billed for additional PNS-END staff time expended beyond the B hour minimum installation <br /> payment.: The party must acknowledge this responsibility for the additional bitting by signature and date below. <br /> Name NANCY VOVES SAFEWAY, IN <br /> Mailing Address 5918 STONERIDGE MALL ROAD PLEASANTON CA 94558 <br /> D'ay Phort Number 5-467-3840-27 <br /> F�.� ,y �� 2� <br /> G t>A- G.�" Oate <br /> Elf 23 DO <br /> EN 23 DOE1012 / c9 may 1994) <br /> 4 <br />