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SAN JOAQUIN COUNTY PUBLIC HEALTH SE•ICES <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 8 TELEPHONE # TEX STOKLEY 209-832-5012 <br /> F FACILITY NAMEJAMAR SERVICE PHONE # <br /> A <br /> C ADDRESS 4075 E. MAIN STOCKTON <br /> I <br /> L CROSS STREET <br /> I ORO <br /> T OWNER/OPERATOR PHONE # <br /> Y1 JAY Mc ILRATH 209-462-8707 <br /> C. CONTRACTOR NAME I PHONE # 1 2 <br /> 0 <br /> N CONTRACTOR ADDRESS p ,0, BOX 1008 TRACY CA GA 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 # TKMT 44-024816 <br /> R <br /> i <br /> I I I I I I I I I I I TANK IRI#I11111111�11 <br /> _ TANK SIZE i CHEN[CALS TO BE STORED PROPOSED INSTALLATION <br /> 39- DATE <br /> T 39- _ <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P III) II IIII II IIII I IIIII11111-111111111111111111111111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII III�IIZZIIIIIIIIIIIIIIIIIII <br /> L �PPROVED APPROVED WITH CONDITIONS) SAPPROVED 1 -30 <br /> J <br /> A ( c TTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME �iY—.O+'/ ./ /"1 '��J LI-G'V�—� DATE <br /> 11111111111111111111 <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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S . <br /> COMPENSATION LAWS OF CALIFORNIA." �Q <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> Indicate the responsi le party to be billed 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 JAY Mc ILRATH — <br /> Mailing AddresS�7S E. MAIN STOCKTON, CA. 95215 <br /> 209-462-8707 <br /> Day Phone Numbeer <br /> Signature '�' � �i1/ Date <br /> EH 23 008 (R /13D 5, US Reg's May 5, 1994) <br /> UST SYSTEM DRAWING [INFORMATION <br /> 4 <br />