Laserfiche WebLink
<A <br /> ENVIRONMENTAL HEALTH D1V1S10N <br /> APPLICATION FOR UNDERGROUND <br /> APPLICATION FOR INSiALLATIOH OF UNDERGROUND TANKS ARE ONLY VALID F <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CAL TANK INSTALLATION PERMIT <br /> PRIOR TO THE END OF THE CALENDAR YEAR. OR THE CALENDAR YEAR IN WHICH IT HAS SEEN I <br /> EHDAR YEAR IF A LETTER IS SENT TO FHS-EHD REQUESTING THIS EXTENSION A ONE YEAR -- ONE TIME EXTENSION ISSUED <br /> MAY 8E GRANTED 8Y PUG <br /> UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS, <br /> EPA SITE # <br /> F FACILITY NAME PROJECT CONTACT 8 TELEPHONE # <br /> A ��-S�/✓,J �6Alf l.f E <br /> C ADDRESS � 3 9 Diq/a <br /> I � STDC,ty i PHONE t� <br /> L cRoss STREET a'"J Si, �tl <br /> 1 -SE C;0 -0 Sr�E�r c� �,,,� (,4c 1F- <br /> T OWNER/OPERATOR 95366 <br /> C CONTRACTOR NAME PHONE # <br /> �� mcf.� cr _ S-g9 _ <br /> N CONTRACTOR ADDRESS 3 05 <br /> T f o 17 PHONE # <br /> R HAZARDOUS WASTE CERTIFIED r• �IDQS?�J CA LIC # e,� p <br /> A YES ' NO 7 V�p 6 LI CLASS <br /> C FIRE DISTRICT C /� 0 [ 61-DYo <br /> I �i F WORK.COI <br /> 0 BOARD OF EQUALIZATION # pN r-7 L6 <br /> R PERMIT # <br /> 1111111111!lANKI j01 X11!1!!11111 <br /> 39- TANK SIZE <br /> T 39- E L CHEMICALS TO BE STORED <br /> A 39- 9 4 p {�._ /�i6j ( PROPOSED <br /> N 39- INSTALL rldN <br /> Lti . i42T"DATE//_4}2 <br /> K 39- L 3 <br /> �-� <br /> 39- <br /> 39- -9 <br /> P 1111 <br /> L <br /> A APRR D APPROVED WITH CONDITION(S) <br /> N PLAN REVIEWERS NAME „r I$EE Ar HMENT WITH CONDITIONS) DISAPPROVED <br /> 11111111111i111l111111 11111111 11 1I11 111 I 1 111 1111 111 11 11 fill 1 DATE <br /> APPLICANT MUST PERFORM ALL ALT !N ACCORDANCE WITH 5AN JDAOUIN COUNTY ORDINANCES, STATE 1 11I11111 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, OWNER OR LICENSED AGENT' AND RULES AHDIREGULAd�ONS10F11111 <br /> THE PERFCRMANCE OF THE WORK FOR WHICH THIS PERMIT S SIGNATURE E LAWS <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> ISSUED, I SHALL NOT EMPLOY ANY TP R THE FOLLOWING: <br /> "I CERTIFY THAT 1N THE PERFORMANCE LIFORNIA." CONTRACTOR'S PENG OR SUBCON R IN SUCH A ��! CERTIFY THAT !N <br /> OF THE WORK FOR WHICH THIS PERMITHISIISSUED, I SHALL EMPLOYIPERSONS SEEM FIES THE R AS TO BECOME <br /> COMPENSATION LAWS OF CALIFORNIA," <br /> JECT <br /> APPLICANT'S SIGNATURE: <br /> TITLEf5 <br /> Iicate the res &71'1 DATE I � <br /> possible party to be bitted for additions{ PHS-END staff time ex <br /> Party must acknowledge this responsibility for the additianal billin bY signature and date below. <br /> FendedYond <br /> g the 8 hour minimum installation payment. <br /> ling Address <br /> Phone N r () CsI <br /> lature `�}! <br /> 1 <br /> 3 Od8 (Rev 1/7/92) WP Date <br />