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i ENVIRONMENTAL HEALTH DIVISION � � APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIITDE( 1994 APPLICATION FOR INSTALLATION OF UND'AS-KXND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT H& P TAL HEALTH A PERMIT MAY BE EXTENDED INTO THE k -:T CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXT T�i" PRIOR TO THE END OF THE CALENDAR YE2. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS -END UPON RECEIPT OF THIS TIER. 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.m.4 APPLICANT'S SIGNATURE:LILI� �i"�✓ •{t� +�7 bt!f9R-. TITLEJ7,6 t(+120i G�!aff DATE Indicate the responsible party to be bitted for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Mai t ing Address 7�/4% U�/1bT. T" ��GN�,.aJMrsltTD�l 4r,�, t Day Phone M`mber_A[L2.1 Si EH 23 008 (Rev 1/7/92) WP C 3 Date (Z --L - `l - EPA SITE # Gr'6TOorM PROJECT CONTACT b TELEPHONE # -,j-1-T F FACILITY NAME -_ PHONE # A C ADDRESS ® I _ L CROSS STREET I T PHONE Y �OOWNER/OPERATOR ` r I e/ -AE116 L[Llt25 2. e CJ CCONTRACTOR 0 NAME d•�.� A4t4gorg PHONE # v." ',� N T CONTRACTOR ADDRESS CA LIC # CLASS/p, R A HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# ds e C T FIRE DISTRICT PERMIT # 0 R BOARD OF EQUALIZATION # „_ a Itllllt11111I11111111111111111 TANK ID # TANK SIZE CHEMICALS TO BE STOREDINSTALLATION p 39- DATE T 39- �.—. A 39- N 39- K 39- 39- 39 - III III P L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME II111111111111111111 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.m.4 APPLICANT'S SIGNATURE:LILI� �i"�✓ •{t� +�7 bt!f9R-. TITLEJ7,6 t(+120i G�!aff DATE Indicate the responsible party to be bitted for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Mai t ing Address 7�/4% U�/1bT. T" ��GN�,.aJMrsltTD�l 4r,�, t Day Phone M`mber_A[L2.1 Si EH 23 008 (Rev 1/7/92) WP C 3 Date (Z --L - `l -