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ENVI <br />APPLICATION FOR UN <br />HEALTH DIVISION <br />TANK INSTALLATION PERMIT <br />APPLICATION FOR INSTALLATION OF UNDERGROLID TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHIM IT NAS NEEM ISSUED. <br />A PERMIT CAR NE MENDED INTO THE NEXT CALENDAR TEAR IF A LIM IS SENT TO MIS -END RIGESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR TEAR. A ONE YEAR -- ONE TIME EXTENSION MAY GR GRANTED By PNS -END UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EN Z3 000 (1w 1/7/92) UP <br />c jqk, fav <br />Ci <br />PAD. 3 <br />r.,\ Y'fV1 F 1•I"f <br />RFcFlVFl) <br />JUN 0 5 1992 <br />SAN JOAQUIN COUTI fY <br />F'UEII_II; mAI_Tl-I S6R P'l <br />rNVIRONMENIALHEALIII Ui.'•'o-'`I^� <br />.-C` <br />EPA SITE t <br />PROJECT CONTACT i TELEPHONE t fsb.S-9L8 _R18*6 <br />v T f4�) N <br />F <br />A <br />FACILITY NAME G <br />- <br />PHONE t <br />zOg <br />C <br />ADDRESS 385 (��ourL/vim c�� s/c C.v 6-37 <br />L <br />CROSS STREET <br />I <br />T <br />T <br />0(AER/OPERATOR <br />C /f/� <br />PHONE t <br />zo9-835'89z� <br />c <br />0 <br />colrucroR NAMES /C55 cc)A, ?-R Gr/orC% <br />P"D'E t �oS p 37-s8si <br />T <br />CONTRACTOR ADDRESS n <br />CA LIC t <br />CLASS <br />R <br />A <br />NAZARDOIS WASTE CERTIFIEDTES _ NO_ <br />YONK.COP.t C__ /`i Sg <br />C <br />FIRE DISTRICT <br />PERMIT t <br />T <br />0 <br />BOARD OF EOl1ALIZATION S <br />R <br />t 111111111111111b1� (l l l 111111 <br />TAIR <br />TANK SIZE CIR311C�Lf TO ! STONED PROPOSED INSTALLATION <br />39- <br />/,2n r -j p C7 flSO1./�.) F. DAT[ - <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />1111 <br />P <br />L _ APPROVED ` APPROVtD WITN CONDITION(S) 01 SAPPROVED <br />_ <br />A (SEE ATTACHIENT WITH CONDITIONS) <br />N DATE <br />IIIIIIIIIIIIIIIII II 11111 <br />APPLICANT "UST PERFORM ALL YORK IN ACCORDANCE WITH SAN JOAa ll CO NTT ORDINAAMS, STATE LAYS, AND RULES AND REGULATIONS OF <br />SNI JOWtV COUNTY PUBLIC HEALTH SERVICES. OWNER OR LIQ AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN <br />THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS 199PD, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A HAMMER AS TO /ECOE <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTMIS NIRING OR 22CONTRACTING SIGNATURE CERTIFIES TE FOLLOWING: <br />01 CERTIFY THAT IN THE PERFORMANCE OF THE YORK FOR WHICH 1011 PERMIT IS ISSUED, 1 SMALL INOLOT PERSON! SLUACT TO VORIER`S <br />COMPENSATION LAMB Of CALIFORNIA. - <br />APPLICANT'S SIGNATURE! �LJG' JJ_�7T-�.e TITLE . )C/lJ OATS 4� b -9z <br />EN Z3 000 (1w 1/7/92) UP <br />c jqk, fav <br />Ci <br />PAD. 3 <br />r.,\ Y'fV1 F 1•I"f <br />RFcFlVFl) <br />JUN 0 5 1992 <br />SAN JOAQUIN COUTI fY <br />F'UEII_II; mAI_Tl-I S6R P'l <br />rNVIRONMENIALHEALIII Ui.'•'o-'`I^� <br />.-C` <br />