INSTALL_2004 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS fS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED, A PERh4IT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR, A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. PROJECT CONTACT: Bob Hill/John Tharp CONTACT PHONE # 559-688-2977 FACILITY NAME: FACILITY PHONE# Rancho San Miguel 209-957-2555 FACILITY ADDRESS: 1409 Airport Way Stockton, CA CROSS STREET: 95205 Charter Way OWNER/OPERATOR Rancho San Miguel Inc. PHONE: 9 209-957-2555 CONTRACTOR NAME: Franzen-Hill PHONE: 559-688-2977 CONTRACTOR ADDRESSf100 North J Stree Tulare CA LICENSE # 304147A/g CLASS: 44201802 DISTRICT: --PERMIT# BOA 2 RD OF EQUALIZATION D 2 -TO Yn TANK ID# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE 1 20,000 87 Octane Gas 7/21 /03 2' 10,000 91 Octane Gas 7/21103 APPROVED APPROVED WITH CONDITIONS DISAPPROVED (see attachment With conditions) PLAN REVIEWER'S NAME DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITS LIED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIF NIA." CO -ACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:"f CERTIFY THAT IN THE PERFORMANCE OF THE WORK FO I T RMIT IS ISSUED I SHALL EMPLOY PERSONS S BJECT TD ORKER'S COMPENSATION LAWS OF CALIFORNIA." // APPLICANT'S SIGNATURE: TITLE DATEIpr17-6-3 Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name Franzen-Hill Mailing Address 1 100 North J et Tulare, CA 93274 Day Phone Number 59/6V-2977 x 3909 Signature Date_ 6 - 17-0-3 EH 23 008 (Rev 3115102) 4