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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: �C' �- / TITLE ; c A -7�-' DATE /-/0-77 Indicate " 0 - Indicate the responsible payment. The party must Name Mailing Address Day Phone Number to be billed fior additional PHS-EHD staff time expended beyond the 8 hour minimum installation Ledge this responsibility for the additional billing by signature and date below. Signature Date EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) UST SYSTEM DRAWING INFORMATION In PROJECT CONTACT 8 TELEPHONE k EPA SITE R CA G 60 �� Te/7- F A ( FACILITY NAME /� S l C, / °A G) �� ' PHONE R/�Lsq� C i ADDRESS p ) ` /) 1 C c Q t 'KS �I; Y",a C' L CROSS STREET _ 7— I l j 1 T Y OWNER h6PE04QRPHONE ( G 7- G��V `% }�C, 1 1 j CONTRACTOR NAME /��/ CO 'r4 l i^C C I� PHONE�� /� ,_ G7 N j CONTRACTOR ADDRESS -3CL ®CA LIC # 7 CLASS // R A HAZARDOUS WASTE CERTIFIED ES NO WORK.COMP.m�� Cs C,C a �7 ±7._ 7 f JJ C j FIRE DISTRICTt '7 PERMIT d li £ � e�-- j 0 j BOARD OF EQUALIZATION Rf R Illllllltltllllllilllllltllttl TANK ID "+ TANK SIZE CHEMICALS TO BE STORED 1PROPOSED INSTALLATION' 39- " OO © r f� �. �_��e,�zc /cz,/� i�lQleo4 i_�/_ DATE r�g T 39- A 39- S LCu.(PrL _ i2%I N 39- C Zr -r- K 39- 9 -39-P 39- 39- lIlli!ll!lI11111111111111111111111111111111111ittllll1111!llllll!lIIIl11ltl1t111111111111111II1111111�l11l1l11111111111111t P L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS 11111111111111111111 NAME DATE 111111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: �C' �- / TITLE ; c A -7�-' DATE /-/0-77 Indicate " 0 - Indicate the responsible payment. The party must Name Mailing Address Day Phone Number to be billed fior additional PHS-EHD staff time expended beyond the 8 hour minimum installation Ledge this responsibility for the additional billing by signature and date below. Signature Date EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) UST SYSTEM DRAWING INFORMATION In