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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 5 m "'�) 51-OI O <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE "Dep- Remo 9 9 O <br /> F FACILITY NAME Joys -P1 N 6 PHONE # O-C <br /> A <br /> C ADDRESS 15&00 S• hFaFd.cY� ( 'o <br /> I <br /> L CROSS STREET Lr�E, <br /> I <br /> T OWNER/OPERATOR PHONE WNp# <br /> Y tXLw tug= DtLezz <br /> C CONTRACTOR NAME PHONE # p f-3 <br /> N CONTRACTOR ADDRESS O3F'f}S'T ��cF'L/�O,(/� CA LIC # �S3Sr� CLASS <br /> T <br /> A HAZARDOUS WASTE CERTIFIED YES_ NO� WORK.COMP.# // T <br /> C FIRE DISTRICT T �' PERMIT <br /> T V <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- / /-2000 G"/4S,O L./d.E 45•+-PFiI -DATE <br /> - <br /> T 39- 1 0f7 <br /> A 39- U ooJ n /EC,F� <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ` 1`-�l TTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME �'1 L l DATE Q 5 <br /> nnuuunnnnnrm menu <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 WFICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI . <br /> NJ <br /> APPLICANT'S SIGNATURE: TITLE 46c <br />