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i 0 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS 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 -END REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS -END UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE # / DObO �6 PROJECT CONTACT 8 TELEPHONE ! 91fl-1-3 <br />f)Lc>(-1Azn <br />ICA L <br />FACILITY NAME USA #' <br />PHONE # <br />ADDRESS 0 <br />CROSS STREET C N4 L <br />OWNER/OPERATOR LA ,5/J (- ASO l..�rc Q6 <br />PHONE # <br />01oI A cr. +F zoo <br />A m v 4;qj.. SIB -S6,§ -4Z00 <br />CONTRACTOR NAME US '4 A. . C.c(p, <br />w„(d PHONE # Q - 6Z2- y2 <br />CONTRACTOR ADDRESS ' Z� i Or L C A&4,VA <br />CA LIC # <br />CLASS <br />HAZARDOUS WASTE CERTIFIED YES_ NO_ <br />WORK.COMP.# <br />FIRE DISTRICT <br />4; <br />PERMIT # <br />C f <br />BOARD OF EQUALIZATION <br />++II <br />TANK ID # TANK SIZE <br />CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- 12 e1no LW L. DATE 814 7 <br />17 tDDO <br />LA L r <br />39-o <br />% pa <br />a LLNL n.. <br />39- O <br />iS p�I.T b�o0D <br />i464LA <br />39- <br />39- <br />39- <br />-11� -11 <br />�IIII I1111111 1-11 Irl md II I I I I I I II I III III II I 1 11111 <br />_ APPROVED 1O APPROVED WITH <br />CONDITION(S) DISAPPROVED <br />EE ATTACHMENT <br />PLAN <br />WITH CONDITIONS) �`rZ-A7 <br />REVIEWERS NAME Ems- <br />DATE <br />PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN <br />COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />Y JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED <br />AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, <br />I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />3JECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />4PENSATION LAWS OF CALIFORNIA." <br />'LICANT'S SIGNATURE: �. <br />//� <br />TITLE ?L a ZI C:PT t/ TE -%TA <br />to the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br />t. The party must acknowledge this responsibility for the additional bitting by signature and date beton. <br />LA s70 P io e u ,A - Co-, A <br />3 Address 9= <br />ane Number_ <br />UST Reg's <br />ITEM DRAWING INFORMATION <br />Date 2_!_s- 7 _?- <br />