Laserfiche WebLink
ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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 YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT & TELEPHONEL!!i <br /> ft <br /> A FACILITY NAME _ ) �9) <br /> HONE c 31 <br /> IADDRESS � — �j „o <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y S t-L L, Q L CC L-FF <br /> 510 UP; -� <br /> C CONTRACTOR NAME —ryy�r i <br /> 0 PHONE # <br /> N CONTRACTOR ADDRESS CA LIC <br /> T # CLASS <br /> R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICT O ( PERMIT # <br /> T D <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIII <br /> 39 T /ID# ¢-7 TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> V _ Ij <br /> I .. C« �f� C�y f�F=r;l /1I� U Lib �15C1IAi DATE ` / <br /> A 39- ' <br /> FmIuM V�lic-T4n�- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P IIII <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> N PLAN REVIEWERS NAME 3/f2 (SE ATTACHMENT WITH CONDITIONS) <br /> IIIIIIIIIIIIIIIIIIIIIIII I IIIIIIIIIIII � - DATE <br /> IIIIIIIIIIIillllllllllllllll IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIII <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 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> ?y <br /> APPLICANT'S SIGNATURE: TITLEDATE <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installationa <br /> The party must acknowledge this responsibility for the additional billing by signature and date below. P Yment. <br /> Name <br /> ;� <br /> Mailing Address 1, L Couvm , �u -� <br /> Day Phone Number 5 0;, <br /> Signature ��� '�(��� L Date 6/1, <br /> EH 23 008 (Rev 1/7/92) WP <br /> �- <br /> Ana&c <br /> (�pJLl�1�ZG�, <br />