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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-EHD 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-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # TEX STOKLEY 209-832-5012 <br /> F FACILITY NAME JAMAR SERVICE PHONE # <br /> A <br /> C ADDRESS 4075 E. MAIN STOCKTON <br /> 1 <br /> L CROSS STREET <br /> 1 ORO <br /> T OWNER/OPERATOR PHONE # <br /> Y JAY Mc ILRATH 209-462-8707 <br /> C CONTRACTOR NAME PHONE # 1 2 <br /> 0 <br /> N CONTRACTOR ADDRESS p,0. BOX 1008 TRACY CA CA LIC # 492743 CLAssA&B&HAZ <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES X NO_ WORK.COMP.# <br /> A <br /> C FIRE DISTRICT STOCKTON PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R KM 44-024816 <br /> 111111111111111111111111111111 <br /> TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- TANK ] 06 TANK DATE <br /> T 39- � "- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> I I I I I I I I I U I III I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I U III III IIS IIIIIIIIIII <br /> P <br /> L <br /> APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SE TTACHMENT WITH CONDITIONS) O <br /> N PLAN REVIEWERS NAME DATE (� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND 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 IN 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 /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S . <br /> COMPENSATION LAWS OF CALIFORNIA." p <br /> JF�� <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> Indicate the responsible party to be bitted for additional PHS-END staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date beLow. <br /> Name TAY Mc ILRATH <br /> Mailing Addres4S075 E. MAIN STOCKTON, CA. 95215 <br /> 209-462-8707 <br /> Day Phone Number �v (�y7� /� <br /> Signature i �/// lyk-,k L Date i / <br /> EH 23 008 (R /13P5, US Reg's May-'5,9 4) �— ' J �� <br /> UST SYSTEM DRAWING INFORMATION (� _ /iV, / ('' �q�, ITD ��'�`' <br /> ��j '7U(w c/ Citi <br /> 4 � *42 <br />