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• • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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-END UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. EPA SITE # CAV 9 IS t 9 o0,7 3 PROJECT CCNTACT & TELEPHONE # T_� T � (415)9'73-1144 15)9'73-11Qr F FACILITY NAMET 6* +'E S�-ra" S€G��►tcE � W PHONE #(fig)Ci4�r A ADDRESS I w _ST 1—ti Ct�GLT +� 957-o4- L CROSS STREET I T OWNER/OPERATOR PHONE # Y ?W-4 RC- C`sf5 Ekfcc- (Sb+ulP A4j y (zp - 4 C CONTRACTOR NAME C,��CK�+b�.! C�t�IIC �A,-na`t FG '�.' � PHCNE ?09 0 )�Celir�-8333 N CONTRACTOR ADDRESS CA LIC #scmt05 CLASS A-Ctot lD4© T R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# © , A C FIRE DISTR[CT� o!� b ..�� PERMIT # T 0 BOARD OF EQUALIZATION # R III 1111111111111 11111 i l l i l 111 l TA C ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION 39- -� (O 1 0 04 CarA1,. I"LEMF-0 G--FaCA-4 .}f - MIN& DATE r 39 101oa0G d— FSFL r7s1 A 39- N 39- K 39- 39- 39- P 1111 1 ff�]T11ITf1111111 L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A ?SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE IIU111111111I111I1111111!111!111111111111111111111111111111111111111111111II111111111111lIIIIIII111111111111lI11I11l11111111 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 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE 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 SIGNA TITLE _P&TECX WMA&QZ DATE Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name F7 SGC G A_-JEJ-EG;4ZlG Co A2&,_ YLATT9 : C 4Z-y PFOM Mailing Address P.O. 8nx T,-C)a MM to CODE �'7�►�y Sbj l FCA&je-AS fA_ & q4- Phone Number (AIS) 1-11-1714A ---1Signature Date� 1^ p EH 23 008 (Rev 12/13 , UST Reg',s��,' May 5, 94) l� l' Gam- �� -�,, � � - Ute•_