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-4 ! • <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT <br />MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE <br />CALENDAR 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: en borne, t I <br />CONTACT PHONE # <br />t�� <br />FACILITY NAME: '0. GI -P L M; (11, - Yn0.rf 4- (V QS <br />FACILITY PHONE# ZO q _j4,7.3 _1 11 7 <br />FACILITY ADDRESS: 4197 11 '>Q,GI PC- AV,, • voCiionCROSS <br />STREET: Ro"o-ri e, L� � <br />OWNER/OPERATOR �,J ,' Sep Ca.(orera_, <br />PHONE: 2-0 -473-117 <br />. _ ! L . � <br />CONTRACTOR NAME: \ o- ( U"ri fi r,l <br />PHONE: �L�. L/ (a 14 _ Za 1k/ <br />(0 59 LiAt.e.r e_ Ovf-• ' <br />CONTRACTOR ADDRESS: I(#(; <br />S- <br />CA LICENSE # CLASS: <br />8 � � (p � �. <br />l I 2 00 9 7 a - <br />FIRE DIS RICI 0'±4 o S•i-cC <br />PERMIT# <br />BOARD OF EOLJAI 17AT16N t' +o 421 10yj <br />TANK ID# <br />TANK SIZE <br />CHEMICALS TO BE STORED <br />PROPOSED INSTALL DATE <br />$ o 0 o <br />Eyt I PlrernI Y JA) <br />z -03 <br />t2 o0D <br />Fye -1 ( Rej--L-hr) <br />03 <br />APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br />(see attachment with conditions) <br />v <br />PLAN REVIEWER'S NAME_ _—_— DATE__ <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SU ECT TO WORKER'S COMPENSATION LAWS OF <br />CALIFORNIA." <br />APPLICANT'S SIGNATURE: — — TITLE --- cv1� —_ DATE _ S'� 3-03 <br />Indicate the responsible party o be billed for additional 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 'kLLr W &;W <br />Mailing Address_ toZco S Crook-ej_ 5d i ck.. ClrGl pJ <br />EH 23 008 (Rev 3/15/02) <br />Pt'Z. <br />