Laserfiche WebLink
Oct-31-97 03r55P a&s engineering 818 842-3760 P.03 <br /> 10-30-1997 1 1 :S7AH FRCNA AS E-M INEER I NG 5109330588 �. 6 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH UIYISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION Of WDERO WD STORAGE TANGS IS ONLY VALID FOR TME CALENDAR YEAR IS WMICK IT NAS SEEN tSSWlD. <br /> A PERMIT NAY If EXTENDED INTO THE SEXY CALENDAR YEAR If A LETTER IS SM TO PRS-EMD REQUESTING TRIS 1XIENS10N THIRTY DAYS <br /> PRIOR TO THE ENO OF THE CALF DO YEM. A WE TIME, ONE YEAR EXTENSION MAT If GRANTED OT PNS-EMD UPON RECEIPT of THIS LETTER. <br /> 00 NOT WRITE IN ANY SHADED AREAL. <br /> EPA SITt R PROJECT CONTACT i TfLEPNORE N i e fADILL A, `510)9 _057 <br /> i FACILITY RM }A �mmPHONE It Z.011� <br /> A <br /> C ADMIN 01WjFST t-jA <br /> 1 <br /> L CROSS STREETLiae <br /> L <br /> T OWIERICOWTOR P�111 <br /> cCONTRACTOR HANE S orJSTR.�C T t O N PHHONE i p� �� 1 <br /> N CONTRACTOR ADDRESS CA LIC fCAST <br /> T ZOc3 E. 5 �IAvJ ci ut5 U 1I 6 -Z ( 9-715] � <br /> R MAZMOOUS WASTE CERTIFIED YES NO WORQ.COIW.tvV'O <br /> A y <br /> C FIRE DISTRICT 1 ( PERNIT 9 <br /> T <br /> 0 BOARD OF EOWI.IZATICN 9 <br /> t <br /> tttltttllt Utl� tll1lltitlll! <br /> AUK B TANK SIZE CNENICALS TO {E STORED PROPOSED INSTALLATION <br /> 39• DATE <br /> T 39- i w <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 111tFtTT <br /> PL APPROVED APPROVED WITH CONOtTION(S) DISAPPROVED <br /> A ^— < TACMHIENT Y1TM CONDITIONS) <br /> N PLAN RETIETIERY NAME /` DATE �r (7 <br /> ittttttlii!!!!i!!1!! 11 <br /> 111111111111111 Hill I IIII lilt III III <br /> APPLICAWT "T PERFORM ALL W]RR IN ACCORDANCE UITH SAN JOIIGUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANO RECULATIONS Of <br /> SAN JOAQVIS COUNTT PtXLIC HEALTH SERVICES. OWER OR LICENSED AGENT'S SIGNATURE CERTIFIES TSE FOLLOWING: "1 CERTIFY THAT It <br /> TNF PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL SOY EMPLOY ANY PERSON IN 3UCM A MANNER AS TO BECOME <br /> RM ACT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.M CONTRACTOR'S NIXING OR SUIICONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: <br /> -I CERTIFY THAT IN THE PERFORMANCE OF TUC WORK FOR WNICe THIS PERMIT IS ISSUED, i SHALL &MOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION tAWS Of CALIFORNIA." \ <br /> APPLICANT'S SIGNATURE TITLE �"^ DATE <br /> IndiCSCa the reaponsibt.a party to be bitted for addiEforsal PH9-00 staff rice expanded bay oed the I hour minimum inetattotton <br /> INIVNI:nt. The party rust acknowtedge this respoMDibititY for tht NNItionst bitting by signature; and dbte below. <br /> Ha i I i ny AddrlttA RDAD- L-1Cm�k'(A. ftw5l/- <br /> DayPbone 0 <br /> -SHgryfure Date <br /> EN 23 oog ( U 's S, 99t) <br /> A <br />