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SAN •_ JAQUIN COUNTY PUBLIC HEALTH S"IC <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLA I PRMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN•11HTC IpXIlS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-ENO REQqjk0I �yX•�,,%EXTENSION TH;lkr 4f <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY �PIIIIS- UPIO7N RECEIPT OF•THS --LLJER. <br /> PERM;7 <br /> DO NOT WRITE IN ANY SHADED AREAS. oO <br /> EPA SITE # N,� PROJECT CONTACT 8 TIE/LEPHON—E # lfbigie lkga as Halm4r) <br /> F FACILITY NAME `�►I�G,r •7_ E1•e. •� _ /UO• 170(o PRONE gjl&71& �y _ 03 <br /> A <br /> C ADDRESSUAY �6t J( ,etlU lke� C� <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y uthl .nd C bka i(n 9a5 2163-,27// <br /> CCONTRACTOR NAME n �7 C PHONE # l�Gy -17T6--3V5(, <br /> 0 <br /> N CONTRACTOR ADDRESS (,IDSf. ple3� CA LIC #dnu <br /> • CJSO CLASS C6/ pyo ///JZ <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES NO_ WORK.COMP.# <br /> A �M <br /> C FIRE DISTRICT D /l ��lC� PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # TV14Q L40- 0047-61 <br /> R <br /> 1111111111 <br /> TANK D 111111111111 <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- DATE <br /> T 39- I lO r nnt7 (y� <br /> A 39- ID/nl)l�a.l elf r ,nrum LGn/✓c de /o ,P <br /> N 39- <br /> K 39- <br /> 39- <br /> 111111 I 11 III 11 11 1 I Iiilll II11 1 1 I 11 1 I illil II 1 I III I I IIIII I 11111111 <br /> P <br /> L APPR APPROVED WITH CONDITION(S) DISAPPROVED <br /> A / i (SEE.RfTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME 'sk/ �/`---�• DATE <br /> 111111111111111111111 TL( III III <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 SMALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.- <br /> ' <br /> ��77 9,l. ''J�� '''��� ,/ <br /> APPLICANT'S SIGNATURE;F�(./L mtp N(///UIe��.- VC l7L LJf".SIGI YI (TK Aj E l l—q <br /> Indicate the responsible party to be billed for additional PNS-EHO staff time expended beyond the 8 hour minimum instaLLation <br /> payment. The party must ackn ie��dge this responsibility for the additional. billing by signature and date below. <br /> Name //IC 114 L 1((Jo,n l.1 nj�,G��up � l rI-, /.�L� /1/! '/` / �] C p <br /> Mailing Address L Q-)1 l I nU�.(�, r1 U`P (/.'(Y'� �-A_.�1.�/��V / I �l.0,�� /1 7Uf l-/'r f-1 Q 'zS <br /> Day Phone Number ( l /u Vv / /, <br /> Signature ,2 Date `y�141 <br /> EH 23 008 (Rev 1 /13/95, U eg's M 1994) ' <br /> UST SYSTEM DRAWING INFORMATION <br /> 4 <br />