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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT CAN RE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS -END REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. EH 23 000 (Rev 1/7/92) WP 3 Pape 3 EPA SITE i PROJECT CONTACT i TELEPHONE i V T f47 N F A FACILITY NATE PRONE i o9 -�F3S -89 LO I "DORESS 3$s 7Z04CY CA 5-37 L CROSS STREET I T T OWER/OPERATOR G /f PHONE i siza I 20 CO CONTRACTOR NAME S / SS CQ.c7 T c9 GT/o� PHONE i (fos - 937-SB"S9 N T CONTRACTOR ADDRESS /JQ G LIC i 33 9,8 mus -/fC9Z R HAZARDOUS WASTE CERTIFIED YES--<- N NCRK-cow.i ��JC- C -A A C FIRE DISTRICT PERMIT i T 0 BOARD OF EQUALIZATION 0 R TAMK ID i TANK SIZE CHEMICALS TO BE STORED PROPOSED IMSTALLIITION TANK 39- F DATE T 39- A 39- — N 39- K 39- 39- 39- I�11 P L APPROVED _ APPROVED WITH CDDITION(S) _ DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOLQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL MOT EMPLOY AMY PERSON IN SUCH A HAMMER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TIME FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. - APPLICANT'S SIGNATURE: It �(�w�L.-iA�l'ml!/�IL� TITLE it -h DATE /= EH 23 000 (Rev 1/7/92) WP 3 Pape 3