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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 15 ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. <br />A PERMIT MAY DE EXTENDED INTO THE NEXT tALENDAA `{EAR IF A LETTER SS SEN' ;Q PHS -S% Rl4M4'l ING VW.S EXTSW510N THl'RTY OAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS -END UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />RAPD �1E 1:� (-73 -,,1 q-2cl <br />F FACILITY NAME I�A�,OV Cr NTE L� � <br />i <br />j07 <br />PHONE # CSC-D3O'✓ <br />�p�7(� <br />ADDRESS ["�j Y) !Z C 1 r'- j C_ A U F j� :� �• 07�i <br />I <br />CROSS STREET pfi'f •^IRs LT <br />I OWNER/OPERATOR <br />I F� t� SAI 2 A 1 le l is <br />X <br />PHONE 9-2 9g8- 300 <br />' CONTRACTOR NAMEA C C <br />PHONE # 07 6 v3 - 29a <br />l <br />1' CONTRACTOR ADDRESS 69 y o IQ M r` r\ i )] Dj /0 tj <br />7 <br />CA LIC a l.� SS I P, I CLASS Q A z <br />! HAZARDOUS WASTE CERTIFIED YES X NO_ <br />t <br />WORK.COMPJS 7i3- j2-oogj , bq <br />STRE OISSAICT <br />PERMIT A <br />I <br />I BOARD OF EQUALIZATION 9 <br />t <br />' <br />IIIIIIIIIll1111111111111111J1t� <br />TANK ID 8 TANK SIZE CHEMICALS TO BE STORED PROPOSED 11(STALLA110N <br />39 - DATE <br />r 39- <br />! 39- <br />c 39• <br />39• <br />39- / <br />rra al <br />_ APPRQVED PROVIV-WlYM COND ITION(S) DISAPPROVED <br />i ,1, ' �� GBEE'ATTA NT ,WITH CONDITIONS) <br />` •"l• <br />=111111H <br />I PLAN REVIEWERS MANE .l, DATE <br />11111 <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! "1 CERTIFY THAT IN <br />TME PEATORMANCE OF THE YORK AOR WRICA' THIS AER141T IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN sticH A WANNER AS TO BEOOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA!' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR .WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALTFDRNIA."- <br />APPLICANT'S SIGNATURE: TSTLE Sft FC ;�cY7RDi UA1JR� SATE-II"i1700 <br />fiaata the responsible party to be bf LLed for additionaL PKS•EHD staff tir" eXperded beyond the 8 hasr minim fnstVkatfor, <br />v t. The party must aQknow Ledge this responsibitity for the additional bitlfng by signature and date below. <br />,e W.Fl CRAIG aOL. <br />Ling Address �7 q L, j <br />Phone Nvnber <br />FA? <br />1, <br />5, <br />n <br />Date 1-11-.2090 <br />9-d vlod---1 WVZV'6 0001, -0L -t <br />