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1• <br />EN ONMENTAL HEALTH DIVISION 10 <br />APPLICATION <br />APPLICATION FOR INSTALLATION OF UIIIOr-A BUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSJEa- <br />A PERMIT MAY BE EXTENDED INTO THE A --XT CALENDAR YEAR IF A LETTER IS SENT TO PNS-EHD REQUESTING THIS EXTENSION ;AItTY DAYS <br />PRIOR TO THE END OF THE CALENDAR TEW- A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN AN%' SHADED AREAS. <br />EPA SITE 0 GI�r® PROJECT CONTACT & TELEPHONE # <br />PHONE <br />F FACILITY NAME FJA�-� lG�, .- <br />A <br />C ADDRESS __ __ <br />i <br />L CROSS STREET elm - <br />I PHONE # <br />T OWNER/OPERATOR <br />Y <br />PHONE # <br />C CONTRACTOR NAME <br />0 CA LIC # CLASS A. Ll A <br />N CONTRACTOR ADDRESS �(� <br />T vE5 NO WORK.COMP.# <br />R HAZARDOUS WASTE CERTIFIED <br />A PERMIT # <br />C FIRE DISTRICT, <br />T <br />0 BOARD OF EQUALIZATION # m (7 <br />R <br />Itttllttttltllll{1lttttttltttl- <br />TANK SIZE CHEMICALS TO BE STORED p DATEETALLATION' <br />TANK 1D # <br />39- <br />T 39- <br />A 39- <br />N 39• <br />K 39- <br />39- - <br />111 tTuTMTMmffl 11 IT- <br />P <br />L ^� APPROVED APPROVED WITH CONDITIONS) �,- DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) DATE <br />N PLAN REVIEWERS NAME nummmmmunnn iifniiiiiii-lillirrrTrgTulrnTr�= <br />'11111111111111111111 <br />APPLICANT MUST PERFORM ALL KIN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUiN COUNTY PUBLIC REACTS SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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 />111 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 CALIF NIA." tt <br />APPLICANT'S SIGNATURE: <br />e L • TITLE ATE ° <br />.. <br />.we responsible party to be billed for , .�� <br />yment— <br />. te madditionsbitting by Signature4 date below. <br />!he party must acknowledge this responsibility for the <br />1/ .... .� <br />L_0(A IIIc. YY. ,.�►' <br />Day Phone r <br />Signature <br />EH 23 008 (Rev 1/7/92) WP <br />j DATE <br />DETACH AND RETAIN <br />FOR YOUR RECORDS <br />I <br />I -- <br />PA!" <br />AMOUNT <br />OF <br />TO <br />T►:E ORIt6R <br />or <br />R , OBEIVT_k.LdE &IATES <br />1137 N. McDOWELL BLVD, A UMA, CA 94954 <br />ENVIRONMENTAL � 90-4021 <br />Pr.,. � _ �� ANATION AMOUNT 1211 <br />ROBERT H. LEE & ASSOCIATES 5151 <br />1137 NORTH McDOWELL BLVD. <br />PETALUMA, CA 94954 <br />707.765-1660 19 <br />WASM 13TON SQUARE ORFICE <br />WESWORICA 203 MC DOWELL RLM <br />PETALLIMA, CA 94063 <br />CHECK <br />AMOUNT ,fir, <br />s �-` <br />6 <br />VOID FTEFt 60 DAYS <br />