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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS 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. DO NOT WRITE IN ANY SHADED AREAS. Indicate the responsible party to be billed for additional PHS-EHD statt time expenaea aeyoilu u1c - - payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name 1011A&CI Mailing Address `7 eJ D < iti�i�Q/✓ 6 7 - Day Phone Number�e% Signature / , EH 23 008 (Rev 12/13/95, UST Reg's GI Date EPA SITE #C Q� f,G/J PROJECT CONTACT & TELEPHONE # ' 1��W / F FACILITY NAME l�c PHONE # G/►�'.- ® A C y ADDRESS V I L CROSS STREET I PHONE # T Yn4ux OWNER/OPERATOR d C r CONTRACTOR NAME )df✓ ® PHONE # I� 0 N CONTRACTOR ADDRESS �G e6� CA LIC CLASS !i R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# r-- 7® A PERMIT # C FIRE DISTRICT T 0 BOARD OF EQUALIZATION # R 111111111111111111111111111111 TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION DATE 39- oAl _ A 39-j non N 39- K 39- 39- 39- P L 1111 APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED (SEE ATTACHMENT WITH CONDITIONS) A PLAN REVIEWERS NAME DATE N 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111I 11111111111111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME THE 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." pp� TITLE DATE APPLICANT'S SIGNATURE: Indicate the responsible party to be billed for additional PHS-EHD statt time expenaea aeyoilu u1c - - payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name 1011A&CI Mailing Address `7 eJ D < iti�i�Q/✓ 6 7 - Day Phone Number�e% Signature / , EH 23 008 (Rev 12/13/95, UST Reg's GI Date