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F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />* At 4g �� <br />SASCAQUIN COUNTY PUBLIC HEALTHISRVICES <br />ENVIRONMENTAL HEALTH DIVIS u <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 <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-EHO UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE # r QL p �� O L�j - QJ PROJECT CONTACT i TELEPHONE # M 1467 L 17; (o 3 7 <br />FACILITY NAME `�,U l rS?� 7 PHONE # 104 q4- -3 <br />ADDRESS 1030 S 0LIVIS A\- F , STOGId-70Aj , CA- 4�751,405— <br />CROSS STREET PSA IAJ 5T <br />OWNER/OPERATOR �sZ J , PHONE S <br />= M�/zc.�5, 510 -&s-?— <br />S -5 zzV <br />CONTRACTOR NAME W+4C,T�r•) E7'J61��-�$INC�� PJC. PHONE # Cfi(�9— 3,73- 163 <br />CONTRACTOR ADDRESS PO (ILjX t ozS W. S�C� `15%� I CA LIC # 6 "' Z 3 8 CLASS )4 t f:�j -t <br />HAZARDOUS WASTE CERTIFIED Y£S NO WORK -COMP.# w C 4 Z -750— 00 <br />FIRE DISTRICT C rry CF STC« (CAV PERMIT 0 <br />BOARD OF EQUALIZATION # © `B -7 (03 <br />l l l i l l l l t i l l l 11111111111111111 <br />TANK ID # <br />39- <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39 - <br />TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />Iz-, C -A c O+JS (JN I, Zk-)L',j DATE Igrf <br />✓+ N h yL n <br />P u11 t tm mr <br />L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />1111111111111111111111111111ITMIIIIII fill11 <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 PERFORMA OF HE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNI . <br />APPLICANT'S SIGNATURE: TITLE DATE <br />Indicate the responsible party to be billed for additionat PHS-EHD staff time expended beyond the 8 hour minium installation <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name_ M 1 KE LFE Ft) tL Owl K- Step MAQ-r c Sl /we- . <br />Ma i t i ng Address 4s(o-7 ghmW2 f 5F -sT , �RUYww7 . CoA- °7-f'673-6 - - <br />Day Phone,�rs-to) i'pS t <br />Signa <br />EH 23 <br />(Rev 12/13/95, UST Reg's May 5, 19%) <br />-11111,71.� " � 1 4 <br />Owner Signature <br />h, <br />Date <br />Date ZB 7QL' c8 <br />