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0 <br />0 <br />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 # Lr p,y) o� g :D 5--1 3 2 PROJECT CONTACT & TELEPHONE # � I I,� ., Lg 1 b) 5 - Zu y y <br />F FACILITY NAME 1Ai�ic�[:xi, r y g PHONE # <br />A <br />C ADDRESS d 1 ��-L �_, Lr <br />I <br />L CROSS STREETS-� <br />I <br />T OWNER/OPERATOR PHONE # <br />Y vniol �; �. (Sig) 9151-4--Io2-2 <br />C CONTRACTOR NAME�,� �r��'�Ur���,,�-}�( PHONE # �c� 1 b C+ Z� _ &��j0 <br />0 <br />N NTRACTOR ADDRESS u.i, 1,J 1M�-("k.�'} [-�1,/� _ CA LIC # to Gi c� -1 g -7 CLASS A,�_-�- <br />T <br />R H 2ARDOUS WASTE CERTIFIED YES X NO WORK - COMP .# rApoV 21 y1np <br />A <br />C F RE DISTRICT- ----- —C � S-6 PERMIT # <br />0 RD OF EQUALIZATI # 0 S� <br />R <br />1111111111 <br />TANK 11111111111111 <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- 1 Z , G.c�) IoY-+ oL+ cst�) -E- ) A o ri Is DATE <br />— <br />T 39- �5�1 000 4 SG'7 0c - ane- 414n-ly `vi.e- 1 aT ci is <br />A 39- . 000 u q 2 0 ; e- '44A4r> G 19� Ci 12- <br />N <br />5N 39- <br />K 39- <br />39- <br />39- <br />P 1111 /` <br />L _ APPROVED _✓ APPROVED WITH CONDITIONS) _ DISAPPROVED <br />A ,,/J p �i (SEE ATTACHMENT WITH CONDITIONS) DATE Z0 - Z-6 <br />N PLAN REVIEWERS NAME <br />11111111111111111111 1 111111111 I 111 <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 />APPLICANT'S SIGNATURE: tn'vl )a _ v+^ TITLEDATE I(::>-IQ-`:i�_ <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name <br />Mailing Address C) �,.►ns1� Sem 1,/j. 2-,2 Le 1� �->o Ccx— �a GA cc �"l N Z <br />Day Phone Number �'1 I lo� b � ra 2-1-1 '-1 `� <br />Signature �-F�z d F �1--� Date 1 d - <br />EH 23 008 (Rev 1/7/92) WP /`" AD 2 <br />3 <br />