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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALMAR YEAR IN WHfCrI IT HAS BEEN <br /> 155UED. A PERMIT MAY DE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER LS SENT TO EHD REOVESTING THIS EXTENSION THIRTY <br /> DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION mAY BE GRANTED BY EHD UPON RECEfPT OF THIS <br /> LETTER. <br /> PROJECT CONTACT: CONTACT P )� <br /> Dennis Cave0 '957-2555 <br /> FACILITY NAME: FACILITY PHONE# <br /> Rancho San Mi uel Market <br /> FACILITY ADDRESS: CROSS STREET': <br /> � Air ort Wa Charter Wa <br /> OWNER/OPERATOR: PHONE:Rancho San Mi uel 209-957-2555 <br /> CONTRACTOR NAME: E:Franzen—HiliPHONE: <br /> ranzen-Hill Car 559-fi88-2977 <br /> CONTRACTOR ADDRESS: CA LICENSE #� <br /> 1 100 North J Street 304 i 47 <br /> HAZARDOUS WASTE CERTIFICATE: YES (NCI WORKERS COMP# <br /> FIRE DISTRICT: 44201803 <br /> City of Stockton PERMIT# <br /> BOARD OF EQUALIZATION# <br /> TANK ID 11 TANK SIZE CHEMIC.�I, STORED PROPOSED INSTALL DATE <br /> 1 " <br /> 15,000 87 ©ctane <br /> 2 12-15-03 <br /> 5 000 91 Octane 12-15-03 <br /> rICAPPROVED PROVED WII4 CONDITIONS 0 DISAPPROVED(see et:achments) <br /> N REVIEWER'S NAME DATE <br /> APPLlCANTMtJSTPERFORWI ALL WORK M 4CCORDA�'CE WITH SAN JOAQUIIV Z;;, rY gRDTN)%NCES,STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES THE FOLLOWrNG"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> PERMIT IS ISSUED.,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SU.BJCCT To WORKERS <br /> COMPENSATION LAWS OF CALIFORNIA."CONTRACTOR'S HIRING Olt SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR"'CH T[lI5 PERMIT IS ISSUED,I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS Or CALIFORNLA." <br /> APPLICAN�ATURUE � <br /> TITLE DA'T'E l a 407— <br /> milli'mum <br /> Indicate the res onsible P party to be billed far additional EHD staff time expended beyond the 8-hour <br /> installation payment. The party must acknowledge this responsibility for the additional billing <br /> by signature and date below_ <br /> Name Franzen-Hill Corp. Date 11 /17/03 <br /> Mailing Address 1100 North J Street Tulare, CA 93274 <br /> Signature Daytime Phone 559-688-2977 <br /> - 3 - <br /> 7� 3 tid NW7J HiAtA <br /> FP17FR9bRg7 TC'gT pan=/aa/rr <br />