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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> n•m ArlLICAT ION FOR INS7ALLAI ION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. <br /> a <br /> pram I I MAY OF FKTFNOFD INTO IMF NEXT CALENDAR YEAR IF A LETTER la BENT 10 PIIq,RND Proul/TIND THIS EK tl nalON THIRTY DAIS <br /> PP19P ID THE CND OF THC CALFNDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LEITER. ' <br /> 00 NOT WRITE IN ANY SHADED AREAS. <br /> EPA__SITE N PROJECT CONTACT It TELEPHONE N N;� <br /> _ G�1�G1S'< SoD SS2?1 / p <br /> r --- TY u— _` (�L -- - A =N`_ PHONE <br /> C .DOBE SS oZ 4�3 �IJ�.IC.1-- —.' ��11LKT� A'� Lam•}}. — — <br /> - 111 <br /> l CRD^,S STPCE7` ( i <br /> X <br /> T OWNER/DP FRAIOR PHONE yy p <br /> C rO47PAC7OR NAM !' PHONE NS 30 - S J O— 6 6 3 <br /> _ �rro �t>rJ_Cpsn^k� loHr�~�- — — — - - - - <br /> �? Asa+ . <br /> I N C041PM1O OR ADDRESS wrq -0 <br /> CA LIC X 3g CUSS <br /> P NA7APOOIIS WASTE CERTIFIED YES - NO_ 40RK.COHP.X 2 r 3 -3C33 <br /> r tlgF OISLgICi <br /> PERMIT X <br /> pkT�.ZVt_ „A 4�_I_ _ <br /> I BOARD OF EDUAIIZATION X ry1Y Y� <br /> — <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIr1 <br /> i t NC 0 N TANK SIZE [NEIN CfLI��O`pE. STORED PROPOSED INSTALLATION <br /> 39 _ 1)( A3 C.. DATE <br /> 39 <br /> 39 <br /> ' b r <br /> --.._.. <br /> u ,9. <br /> IIIIITmmrrrrTlIITITTTT frTrrr rmrir rm1lmmmrrlrrr <br /> , APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DALE <br /> im ii,,,I I un,,,mm�rrmTrnrntrmm�nntmrrmrrrmmnntrrrmrmmrrnnnmrrmm rtmrrmnrr <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOA^VIM COUNTY PUBLIC HEALTH SERVICES. .OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAI IN <br /> THE PEgFORPANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> ^13tECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> CERIIFI ]HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT 70 WORKER'S <br /> ro-rFNSA710N LAWS OF CAL IFO IA." <br /> AI'+LICAN—S SIGNATURE: TITLE C 1'JVIt-U^ i j'b✓ DATE <br /> .�dicate the responsible party to be billed for additional PNS-END staff time expended beyond the 8 hour minimum installation <br /> pmpncrt.The party must acknowledge this responsibility for the additio�nL1�\I billing by Signature and date below. <br /> ua L <br /> �1'3 Z3Z—C <br /> QA i bEJC tLn Cai t fN�`'ZIA - 00\n - <br /> Gn✓ 'vh-ne NWrbar_(JAO ^ — L 11 _ U�, /�/y ---- <br /> Date / <br /> FH 111:rP, (R,v 11/17/95, UST Reg's May 5, 1994) <br /> 4 <br />