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4/ SAN JOA m COUNTY PUBLIC HEALTH SERVIC <br /> ENVIRONMENTAL HEALTH DIVISION � „" <br /> G APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATI0IPPERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAROIN�HHIC# I"CHAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHO REOUES�I�I�"+pMI&.EXTENSION. THIRTY, ❑ S. <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED SY P S- HD`UPON RECEIPT OF THt4glff7ER. <br /> 00 NOT WRITE IN ANY SHADED AREAS. PERNIJ ''`'�`-+�J <br /> EPA SITE # NIR PROJECT CONTACT 8 TELEPHONE # / C9r DO <br /> ' / Debbi e2 bQ Lct� �C!liltQn <br /> F FACILITY NAME SCic4h ik rd 7- E �.e J,en N0. l71o�llo I PHONE �� •] <br /> A /C� / //'' n 7 J <br /> C ADDRESS (� <br /> I <br /> L CROSS STREET �n <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y � �% `1111Ccnd CD c�2cctldra 9a5 �G3-�7// <br /> C CONTRACTOR NAME B 4� C Y�L I PHONE # liJDy ir�5_ yam/ <br /> O cL 7 J y' <br /> N CONTRACTOR ADDRESS <br /> T 1ID CARS{ — LI x j LAss/� c'i1/ID VO /f�fz <br /> R HAZARDOUS WASTE CERTIFIED YES No WORK. .x <br /> A / <br /> C FIRE DISI Rf CT D T- YN n`k C� PERMiT # <br /> T TL <br /> 0 BOARD OF EQUALIZATION x -'r L IU_ 06)2.Zt <br /> R 1 <br /> I I 1111111111111111111111111111 ! <br /> TANK 10 # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- <br /> 39- 16Y Urllrlorj�ej - <br /> OATE <br /> N 39- <br /> K 39- <br /> 39- <br /> P Illlliliitlllill11111111111111 II1111111111 1 f �l 1111111 Ililllltllllilllll11111111111111111111111111IIII1111111111111 <br /> L APPROVED APPROVED WI7H CONDITION(S) DISAPPROVED <br /> A �% ,(S .ATTACHMENT WITH CZNDITIONS) / <br /> N PLAN REVIEWERS NAME DATE �/ <br /> i l l i 11111111 i i l l l l i l TTITffllTfIDTffi 11111 <br /> APPLICANT MUST PERFORM ALL 'WORK IN ACCORDANPJ WITH SAN JOAQUIN "INTY 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 T E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT' TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." Q LL ,/[ <br /> APDL ICANT'S SIGNATURE• API L Y �� `�� .S']'i /l1WYfE mhq , <br /> I r <br /> Indicate the responsible party to be billed for additional PNS-EBD staff time expended beyond the B hour minimum instaLLation <br /> payment. The party m{u�sLt�ackno <br /> wle <br /> dge this responsibility for the additional billing by signature and date below. <br /> Name <br /> Mai ling Address ll//fin/ // <br /> Day Phone Nunber ( l l W OV <br /> Signature Date <br /> EH Z3 008r(Rey 1 /13/95, UST Reg's M 1994) I <br /> UST SYSTEM DRAWING INFORMATION <br /> 4 <br />