Laserfiche WebLink
Y wl•w Iuv -', ISL "In UIVIJIVIV 1 <br /> APPLICATIONORUNDERGROUND TANK INSTATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE NO OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHO UPON RECEIPT OF THIS LETTER. <br /> / 00 NOT WRITE IN ANY $HARED AREAS, <br /> EPA SITE 9 � PROJECT CONTACT 8 TELEPHONE N p T VlC <br /> F FACILITY NAME p H c v PHONE Y <br /> A ADDRESS <br /> I ATH T <br /> RD L /,s:iIT CI I- `^. �. G 5 Sn _ <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR pXON t <br /> T T N iZTH I l�I�l =NC- Q -t4 <br /> C CONTRACTOR NAME \ PHONE K •7 2 _ <br /> 0 <br /> M CONTRACTOR ADDRESS -7RO Luce RIME. O12. STC. 3 CA LIC ° (� j0-� CLASS <br /> T _ <br /> RHAZARDOUS WASTE CENTIFIEDSUNNVv. Ate, ' N�'y0`' ��103!„ <br /> A WORK.CCMP.tl <br /> C FIRE DISTRICT PERMIT 4 <br /> T <br /> 0 BOARD OF EQUALIZATION d <br /> R LK _ <br /> III!11111111111111111111111111 <br /> TANK ID 0 TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- <br /> „�' DATE__._ <br /> T 39• t} I L nno ... EC:u LH f2 ,I! yll-'F�1�_5(l,•"'_ <br /> A 39• <br /> N 39- <br /> K 39- <br /> 39- " <br /> 39- <br /> P II11fTfffff fTMTffITI1f1TT ffflflTffffMT]MiiiiiiiiiiiiiiiiiiinT=ffffffrw <br /> L APPROVE APPROVED WITH CONDIYION(S) DISAPPROVED <br /> A _-�- ANF ATTACHMENT UITH CONDITIONS) <br /> N PLAN REVIEWERS HARE DATE <br /> Itl►l►nlllllltutull t f T I rfflTffffITITTMTrnTiTfttT MIFrrffrjIM] l l`fr M11111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SMALL HOT EMPLOY ANT PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT 1N THE PERFORMANCE OF TME WORK FOR RICH THIS PERMIT 1S ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CA41FORNIA." <br /> APDLICAN7'S SIGNATURE: - '`C n. A fes, TITIERQI i 17•E11F I DATE (17 fA <br /> ndicate the responsible party to be billed for acWitional PH$•EHO staff time expended bey«4 the 8 hour minim installation payor nc. <br /> he party must acknowledge this responsibility for the additional billing by signature arw date below, <br /> ame �Pf\>;TH-I I A N TIV _ <br /> ailing Address_//11 ! r-'ERLIt/12Z �(., MTC � � 7 f3ijNt -f-UN <br /> ,=iC Co . GN696 <br /> sY Phone Ntmber1�� U <br /> ignature Dace 21 17 <br /> 1 23 008 (Rev 1/7/92) WP <br /> G� 4 i 4A « �r--b2 aU :rJspe�+ads <br /> ^leo <br />