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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STO,RAGE,TANOINSTALLATION PERMIT <br />(' NC'K) Ttatb:na SUinp,tonjc �u�e o�ert�li prt+s. G�d'� '�jc'r A. cusp. Pat^s� <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS 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 TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />Indicate the responsible party to be billed for additional PNS-EHD staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name <br />Mai t ing Address 15V W11 k w ra-25r F.02C <br />Day Phone Number (516) <br />Signature <br />r� <br />EH 23 008 e ,15V13/ <br />UST Reg's May 5, <br />M <br />Date1°�� <br />EPA SITE #I <br />PROJECT CONTACT 8 TELEPHONE # z'VG VL)iy) 0 i(f) C,- S�3_ 76007 <br />F <br />A <br />FACILITY NAME LjnoC�al I <br />F2G� �t # 54 t / PHONE # � L�>g �3-76 J6 <br />CADDRESS <br />1 <br />M 2 t��, <br />L <br />I <br />CROSS STREET H' ��� <br />T <br />Y <br />OWNER/OPERATOR <br />�o��c� IV1 a r k�,�, ►� = <br />PHONE # <br />Cel 767 2 <br />CO <br />( CONTRACTOR NAME olch per} I (}'P U <br />PHONE # gofO G1 -1z _ d6' & <br />TCONTRACTOR <br />^ t <br />ADDRESS 9?,/i ITI��� Ve . C 1 i' t-1 cZ) t) <br />CA LIC # 316,575 CLASS A 5C c iv <br />R <br />HAZARDOUS WASTE CERTIFIED YES O. NO <br />WORK. COMP—" 1717C ( 1 62- <br />A <br />-35i <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />BOARD OF EQUALIZATION # <br />R <br />II1i11fIIII111fIiII11111I11111 <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATIONI <br />39- DATE <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />1111 <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME k DATE Z. 1� Q <br />flfllitflllllllflllllfl 1111 II11 11 III1 f Ifllllifllllilllfllfllillff111111111111111111111 If 1111 Illllflfllllllilllf <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 />LL� T <br />APPLICANT'S SIGNATURE GZtE9%�G��f��c (� 1ZHL L-11-5$ ;y! L-7f11:.'j �. IM,.'� TITLE ._ ?yf �cT:~ ID�G1 DATE Z 4 <br />Indicate the responsible party to be billed for additional PNS-EHD staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name <br />Mai t ing Address 15V W11 k w ra-25r F.02C <br />Day Phone Number (516) <br />Signature <br />r� <br />EH 23 008 e ,15V13/ <br />UST Reg's May 5, <br />M <br />Date1°�� <br />