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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 PNS-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-EHO UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum instattation paymenz. <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Mailing <br />Day Phone Number <br />Signature Date <br />EH 23 008 (Rev 1/7/92) WP �-e q,M <br />e <br />�2U 0/ - <br />%a< d,,�j <br />{ <br />-sum <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # Jim Brown -(209) 468-4540 <br />F <br />FACILITY NAME <br />Hosuffal <br />PHONE # (209) 468-6166 <br />A <br />San Jaaauia Genera <br />C <br />ADDRESS <br />CA 95231 <br />t <br />L <br />CROSS STREET <br />I <br />TY <br />OWNER/OPERATOR San Joaquin County <br />PHONE # (209) 468-2180 <br />C <br />CONTRACTOR NAME <br />PHOHE # (209) 983-0155 <br />0 <br />N <br />CONTRACTOR ADDRESS <br />CA LIC # 218674 <br />CLASS A and B <br />T <br />R <br />HAZARDOUS WASTE CERTIFIED YES <br />NO <br />WORK -COMP.# 006CK713869SSA, <br />A <br />C <br />FIRE DISTRICT <br />Er Cama Eira <br />•Ct- <br />PERMIT # pp <br />Application Attached <br />T <br />- -each <br />0 <br />BOARD OF EQUALIZATION # SsoNsn-RR477� <br />R <br />llll Iltlllltllllllltllltltllll <br />TAN ID # <br />TANK SIZE CHEMICALS 70 BE STORED PROPOSED INSTALLATION <br />39-� -- b <br />DATE <br />T <br />39- 10,000 <br />Calions Diesel Ti ei -45 70 5 <br />A <br />39- <br />N <br />39- <br />K <br />9- <br />39- <br />39- <br />39- <br />39- <br />39- <br />P <br />tltl III <br />11111111111111 <br />E� CQ <br />DISAPPROVED <br />L <br />APPROVED <br />APPROVED WIT CONDITIONS) ® <br />A <br />_ <br />(SEE 7ACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />Illlltllllllltllllltl I I <br />DATE <br />t IIIIIt ! tt 1 # 1 t1 1 <br />APPLICANT <br />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. <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SMALL 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 CALI RNIA.'° <br />ffy} �I,�� <br />TITLE t M 5®✓ DATE <br />APPLICANT'S <br />SIGNATURE: <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum instattation paymenz. <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Mailing <br />Day Phone Number <br />Signature Date <br />EH 23 008 (Rev 1/7/92) WP �-e q,M <br />e <br />�2U 0/ - <br />%a< d,,�j <br />{ <br />-sum <br />