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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 $ PROJECT CONTACT 3 TELEPHONE $ TEX STOKLEY 209-832-5012 F FACILITY NAME JAMAR SERVICE PHONE $ A Aopaess 1 4075 E. MAIN STOCKTON L CROSS STREET T OWNER/OPERATOR PHONE $ Y JAY Mc ILRATH 209-462-8707 C CONTRACTOR NAME PHONE it 12 u CONTRACTOR ADDRESS p.0. BOX 1008 TRACY CA CA LIC $ 492743 CLAssA&B&HAZ T .R HAZARDOUS WASTE CERTIFIED YES X NO WORK.COMP.$ A C FIRE DISTRICT t STOCKTON PERMIT $ 0 BOARD OF EQUALIZATION $ R MWMM AA— 24 16 �I 11111111111111111111111111111 � TANK f �� TANK SIZE I CHEMIC LS TO 3E TORED 39- !PROPOSED INSTALLATIONI _ � 39 �r I—� ATE A 39- 4� 4 39- K 39- 39- 39- P IIIIIIIIIII11111111111 111111 II Illtllllll IIII 111111111111 II11 111111 illllllllllllllilllllllllll�lllllilllllllllllllli _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A (SEE-ATTACHMENT CONDITIONS) l� V PLAN REVIEWERS NAME / > > A_LC DATE Q [ 11111111111111111111 111111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME UBJECT 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 OMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: N TITLE DATE Indicate the responsible party to be hilted 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 ,TAY Mc ILRATH Mailing AddresJ075 E. MAIN STOCKTON, CA. 95215 Day Phone Numb/er 2009/x-462-88�7��07 / /1 Signature / �/��//� /p//_ra ��f Date EH 23 OD8 (R /73 5, US Reg's May 5, 1994) UST SYSTEM DRAWING INFORMATION „ ^ � rr Imo^ / 4