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SAN JOAQUIN COUNTY PUBLIC HEALTH SIVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. nn NnT UOITF IN ANY SHADED AREAS. Indicate the responsible par to be billed g6 additional PHS-EHD staff time expended beyond the o ndu, llilllljl,w., a.•..•• payment. The par-tYy�must ac ouLedge this res�Tn-sibility fortheadditionaak billing by signature and date below. Name / / C 0 71 / r a- C7-0 0 r-5 .J-- 'Y. // T I.�C� Mai ling Address S.3.S W I W 0�- 77, y 7 e) C ^ ' " `� ?S 015 Day Phone Number (,9 0 9) 'i- '- 3.37 Date Signature EH 23 008 ( v 2/13/95, UST Reg's y 1994) UST SYSSTT G AWING INFORMATION O'er � �++C q— EPA SITE #// PROJECT CONTACT & TELEPHONE # F FACILITY NAME P-1 I A T ST PHONE A C ADDRESS ( I e v - I L 7 CROSS STREET o u71 l y., o I IV CL I PHONE # T OWNER/OPERATOR O q\ q ) / Y Mr, Trm M r Cf C CONTRACTOR NAME EU -re- Z= C o til Tti^ a c% Y'S Xr C PHONE # Ocr q.G l — G 3 3 0 NOR T� ADDRESS CONTRACT2 5" 3S (� / W aryyT •Yrs CA LIC # ,4H/4Z G (< OOi CLASS TWORK.COMP.# R HAZARDOUS WASTE CERTIFIED YES_ NO_ .2 X00 .54Z- 9 / A PERMIT # C FIRE DISTRICT Ts 0 BOARD OF EQUALIZATION # KHE "Tcl f'7 300 R 111111111111111111111111111111TANK # TANK SIZE CHEMICALS TO BE STORED PROPOSEDDATETALLATION — ID 39- 3 39- A 39- N 39- K 39- 39- 39- P L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A T H WITH CONDITIONS) `3 I N PLAN REVIEWERS NAME DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN A MANNER AS TO BECOME THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S "I CERTIFY THAT IN THE PERFORMANCE OF THE ENSATION LAWS OF CALIFORNI " TITLE /V'O L ppy— 1 ec-I �✓Y'h' DATE ICANT'S SIGNATURE: —T Indicate the responsible par to be billed g6 additional PHS-EHD staff time expended beyond the o ndu, llilllljl,w., a.•..•• payment. The par-tYy�must ac ouLedge this res�Tn-sibility fortheadditionaak billing by signature and date below. Name / / C 0 71 / r a- C7-0 0 r-5 .J-- 'Y. // T I.�C� Mai ling Address S.3.S W I W 0�- 77, y 7 e) C ^ ' " `� ?S 015 Day Phone Number (,9 0 9) 'i- '- 3.37 Date Signature EH 23 008 ( v 2/13/95, UST Reg's y 1994) UST SYSSTT G AWING INFORMATION O'er � �++C q—