Laserfiche WebLink
1 CERVqED <br /> 0 <br /> SAN JOAQUIN COUNTY Lq <br /> ENVIRONMENTAL HEALTH DEPARTMENT FEB 1 0 2004 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> ENVIRUI yj����/�1� <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH T ,SUC-D:��WRMIT MAY <br /> BE EXTENDED INTO THE NEM CALENDAR YEAR 1F A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRfOR'l O _'C `t{E CALENDAR <br /> YEAR. A ONE TIME.ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> PROJECT CONTACT: PN f~`!E L ACONTACT PHONE# ,. <br /> ycti1LES 7i 4 15l<'7- <br /> FACILITY PHONE# <br /> FACILITY NAME: A R C O (p ( (o Z3� $ZS- (a7$`f <br /> rn A raTEC R 1 CROSS STREET: <br /> FACILITY ADDRESS: O 0 S rY1 R 111 ST <br /> OWNER/OPERATOR 610PHONE: <br /> g12co C5o3� �Z314- '316 <br /> � o <br /> CONTRACTOR NAME: ---F A 1 T PHONE: '7i4-151,'7- 6400 <br /> OONTRACTOR ADDRESS: _ �} CA LICENSE# //�� C p CLASS: <br /> HAZARDOUS WASTE CERTIFICATE: rjYES nNO WORKERS COMP # <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE <br /> PROVED []APPROVED WITH CONDITIONS DISAPPROVED <br /> ee attachment with conditions) <br /> PIAN REVIEWER'S NAME DATE 2 I&A <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN <br /> COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE <br /> OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION <br /> LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE <br /> WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> APPLICANTS SIGNATURE: �CZ�,�L��•� Ce TITLE �o-u -�nH nn �.r DATE <br /> Indicate the responsible party to be billed for additional 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 '1-R IT ;R.\\4 . SyST�T�S <br /> Mailing Address S b j JJ • NEVI LLC- r`•� 0?_A,, 6,E OA <br /> Day Phone Number <br /> Signature a u_ e- �f-e,_ Date_ I /D'� <br /> EH 23 008 (Rev 3/15102) �EPL�°rC.ED,, i'YIEGH A►�� L►4•l- (gip- 1{ '��"���'� <br /> A Tl jt-S 5 ESQ IFR CI I I_t 7-,L_/ I Is S P F C,7`1 6 Q <br />