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SAN..�AQUIN COUNTY PUBLIC HEALTH Sc-VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATIOrRIN <br /> RMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR WHICH IT HAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTV6 THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY P -EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE # <br /> dill h (9254103 -2711 <br /> F FACILITY NAME 50v}}T1W1J 7-eleven Sure 17Co47 PHONE # <br /> A �/ y <br /> ADDRESS <br /> 1 10415 W loSCmf1'¢ Ave. <br /> I <br /> L CROSS STREET �� POr-f•3I A✓e <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> T The (`125) 4 &3- 2711 <br /> C CONTRACTOR NAME _VionefVs Wr ration PHONE # <br /> D (5e02)59s-4555 <br /> N CONTRACTOR ADDRESS IlO1 E• Sorin �11G�1 CA LIC # SS3lo33 CLASS A b FK3' dh ' <br /> T Glz ezl eV G577 <br /> R HAZARDOUS WASTE CERTIFIED YES CK NO WORK.COMP.# w GSl�gd3� <br /> A <br /> C FIRE DISTRICT <br /> T ERPMIT # <br /> 0 BOARD OF EQUALIZATION # 7Y HQ 44 - 2 I <br /> R <br /> 111111111111111111111111111111 / <br /> TANK ID # TANK S . E CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- DATE <br /> T 39- U 7r c fir• (ZR1'�— <br /> A 39- { OII PremivM Unle9 o� <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111 1 111111111111111111111 111 111 111111 1111 111111 1111 I 111 I 1111111 II I 111 11111 it <br /> L AP�40 D APPROVED WITH CONDITION(S) DISAPPROVED <br /> A / (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 11111111111111111111IIIII If TI I fill 1111111111 In I I 1111111111 111=1 11111111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEAL SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK F R WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENS ION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PE ORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL ORNIA." .-ma �Y <br /> APPLICANT'S SIGNATURE: M+w+• (oF FHL �S1G�i'1 (XouP�ITLE A%!I'y, To ��IanJ DATE 4 1&0 9a <br /> Indicate the responsible party to be billed for additional PHS-EHD 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 R14U 1;>aoiejn &roup ,e, InG,.^d <br /> Maiting Address660 Howes A/enu0+ �7'dGC2MCntq G/, �=JaZj <br /> Day Phone Nunbeerr�(11&) Co4& -4p03 <br /> SignaturgJ(Q a,--,;. Date fl'�1lc/9Q7 <br /> EH 23 00 (R v PZ/13�i, UST Reg's May 5, 1994) <br /> UST SYSTEM DRAWING INFORMATION <br /> 4 <br />