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W.1 V U-t <br /> r --------- L.r rt\i L.rV. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> AFPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FCR INSTALLATION OF UNDERCROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN VHICH IT HAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-END REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY aE GRANTED BY PHS-ENO UPON RECEIPT OF THIS LETTE <br /> -' CO NOT WRITE IN ANY SHADE.^. AREAS. <br /> EPA SITE * C c <br /> A'L C O O S1 C c, 1- Q ' PROJECT CCN TACT 3 TELEPHONE S <br /> — I � �� <br /> F FACILITY NAME ( �1"�T'Ct_MQ..t znC- .,. <br /> ������ PHONE x U,.w--�cCO`1-2�iC34 <br /> ADDRESS (e- Ir1'\ CIA <br /> L CROSS STREET Lcw�r �a�r-cu-�,w,-t� <br /> I <br /> T OWNER/OPERATCR PHONE f <br /> S$3 —3zc;-7 <br /> oCONTRACTOR NAME W,) 1-to N En ; n r i+nz� (�+� . ! PHONE <br /> N CONTRACTOR ADDRESS CA LIC # ( '' Q., I CLASS Q I $, <br /> T VV <br /> R I HA2ARDCUS WASTE CERTIFIED 7°S _ NO ' WCRK.C^MP.a {{G 0-L01 <br /> (0 D �q <br /> LFIRE C DISTRICT G•oDl Y�.�C:, !��! —'" '� PERMITT 5/��� r a �� X33-� <br /> 0 oCARO OF EQL'ALIZATICN 4 i <br /> IRI <br /> 1111111111111111111III1111IIII <br /> TANK ID ;9u 1�TANK SIZE CHEMICALS IO BE STORED PROPOSED INSTALLATION <br /> 39- <br /> T <br /> 39- � � i DATE <br /> A J39- <br /> 4 39- �, 1 <br /> K 39- <br /> 1 39- v <br /> 1 39- <br /> Illi <br /> FA <br /> � APPROVED APPROVED WITH CCNOITICN(S) DISAPPROVE) <br /> (S' TTACHMENT WITH CONDITIONS)PLAN REVIEWERS NAMe' ll�'6 �y' DATE - <br /> lIIlI1il11111I1111II 111 11 1III f I it 11111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN AC'r.CRDAN=- WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN CCUNTY PUBLIC HEALTH SERVICES. NWER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS ?ERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WCRKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR I S.HI RING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I C:RTIFY THAT IN THE PERF C'c OF THE WCRX FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CCNPENSATION LAWS OF CALI RHI �" <br /> APPLICANT'S SIGNATURE. "r,`�-� TITLE t4E r� s TSU DATE <br /> Indicate the responsibte party to be bitted for additional PHS-EHD staff time expended beyond the 3 hour minimum instaltation payment. <br /> The party must acknowledge this responsibility for the additional bitting by signature and date beton. <br /> flame LL«Y'C �a-� t(\G. 14 t+0: ncG r�Cc <br /> fai t ing Address 1e.i C1 G?4 x3 2-30 <br /> lay Phone Number 5'83 u <br /> ignature �j.+t\CQ'�GL FZ. :/til Cate Q -a-'s _ <br /> 4 23 003 (Rev 1/7/92) WP <br /> 3 <br />