Laserfiche WebLink
• <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN IS <br /> A PERMIT CAN BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-END REQUESTING THIS EXTENSION UED. DAYS <br /> S71Ey, <br /> PRIOR TO THE END OF THE CALENDAR YEAR- A ONE YEAR ONE TIME EXTENSION MAY BE GRANTED BY PHS-END UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS, <br /> EPA SITE H PROJECT CONTACT L TELEPHONE <br /> F FACILITY NAME <br /> A J JO C.KVC)Aj f.(SEL-!J/�/I'/ iCJ I%L CGT/Z PHONE # 2o9 <br /> ADDRESS <br /> I -/o C iyjlpG-N0Gt 5% <br /> L CROSS STREET /Vr <br /> I <br /> T OWNER/OPERATOR PHONE i <br /> T /F. DEPT <br /> 0 CONTRACTOR NAME s /ESS U cTi O PHONE : -9 3? -SSSS <br /> NCONTRACTOR ADDRESS O' ) a4x 2 CA LIC s 3339$ LQA� — p <br /> R NAZAROOIS WASTE CERTIFIED YES, No IJORK.COP-! Tr-vG 1��7Sp <br /> A <br /> C FIRE DISTRICT <br /> T PERMIT ! <br /> 0 BOARD OF EQUALIZATION ! <br /> R <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br /> 39- ON <br /> TANK ID / TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> T - <br /> DATE <br /> A d i % S FL <br /> -SDC - 3 /d . 0o(9 -21C <br /> K 39- - - /O -L <br /> 39- ,S io. einem <br /> 39- - G -O <br /> IIII <br /> P <br /> L 1-/APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE �'l/fl I�2-- <br /> IIIIIIIIIIIIIIIIIIII 1111111111 tmI I I I I <br /> fffffffffrffffrfffffffffffffff <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AMD 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 SHALL NOT EMPLOY ANY PERSON 1N 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 /> •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.- <br /> APPLICANT'S SIGNATURE: / /moi// _ TITLE .:5 DATE <br /> EH 23 000 (Rey 1/7/92) WP page 3 <br /> - 51]C - O� IO o0 &-4 4, (9ASoc /AJ <br /> 3 <br />