Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br />APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WICK IT HAS SEEN ISSUED. <br />A PERMIT CAR BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER 13 SENT TO PNS -END REQUESTING TRIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION RAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTEP. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EM 23 000 (Rev 1/7/92) W <br />Page 3 <br />PAYMENT <br />RECEIVED <br />J U N 0 5 1892 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVIC.S <br />3 ENVIR0WvlENTALHEALIH6id,'��".! <br />EPA SITE i <br />PROJECT CONTACT L TELEPHONE i�US <br />F06--gea-3/T6 <br />T &z j A.) <br />F <br />FACILITY NNE <br />PHONE i O,'p —,F E-9 2:0 <br />C <br />ADDRESS _3195 &,2A,u7-L/.V E RP AG <br />GO (?5-37 <br />1 <br />L <br />CROSS STREET <br />I <br />T <br />Y I <br />OWER/OPERATOR <br />c /f p <br />PHOW i <br />z o 9- 8p.3s- & 9Za <br />U <br />/_ <br />caTRACTOt NNE S -�5"s LGN 7-RO GT/O� <br />PHpIE <br />N <br />CONTRACTOR ADDRESS P"O 8ox Z. �9 S�✓✓um ff%i0 �/� <br />CA LIC s <br />3 <br />%8 <br />CLASS <br />T <br />R <br />HAZARDOUS WASTE CERTIFIED YES - NO_ <br />YORK -COV.# C,- /C/ 75 g' <br />A <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />SOARD OF EQUALIZATION # <br />R <br />1111111111 <br />TANK 11111111111111 <br />D <br />TANG ID i TANK SIZE PROPOSED INSTALLATION <br />DGdES <br />39- ['� O S(9 <br />DATE <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />1111 <br />L <br />A <br />APPROVED APPROVED YITN MTION(S) <br />( E ATTAC WIT CONDITIONS <br />_ DISAPPROVED <br />M <br />PLAN REVIEWERS MAZE4171.1 <br />DATE <br />11111111111111111111 <br />11111 flrff <br />APPLICANT MUST PERFORM ALL YORK IM ACCORDANCE WITH SAN JOAQUIN CCNW ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IM <br />THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO RECCE <br />SBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S MIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />•I <br />CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS ABJECT TO YOXER'S <br />COMPENSATION LAYS OF CALIFORNIA.- ' <br />APPLICANT'S SIGNATURE: iC Frjl! % _ - i/f TITLE <br />r / <br />�C- DATE 7 <br />EM 23 000 (Rev 1/7/92) W <br />Page 3 <br />PAYMENT <br />RECEIVED <br />J U N 0 5 1892 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVIC.S <br />3 ENVIR0WvlENTALHEALIH6id,'��".! <br />