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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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-EHO REQUESTING THIS EXTENSION THIRTY DAYS 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. 00 NOT WRITE IN ANY SHADED AREAS. EPA SITE # G` A �Q^ PROJECT CONTACT L TELEPHONE #C,SVSI 76C V SON 51.0-t4Z7 � F FACILITY NAME !�L-N L SU 1T QO PHONE # p-Li -23 A C ADDRESS CQ C I LA-0 LJ f 10 QC1 L CROSS STREET S jo I T OWNER/OPERATOR PHONE # Y LL-N L S 10 - H IS-4S 1) C CONTRACTOR NAMEP PHONE # 0 N CONTRACTOR ADDRESS q�SC4IY.%rnI:ICc.. ST JQ.+.T�SZ. CA LIC # 5010 -?S CUSS A . t�2 I,rjo T R HAZARDOUS WASTE CERTIFIED YES,K_ NO WORK.COMP.#�w -a-ax 3,,i.0o A C FIRE DISTRICT LC,y` PERMIT # T 0 BOARD OF EQUAL I ZAT ION #54 Cw N D E7_ y r)bol C 1 R Ilillliltlllllllilillllllll111 TANK IO # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION 39. 1.9�/S I S�Q� G050w►g I— _j_DATE CtL4 T 39- A 39- H 39- K 39- 39- 39- P 111111111111111111111� 11111111111111 11111111111 L _ APPROVED PROVED WITH CONDITION(S) _ DISAPPROVED A EE A TA Mf WITCONDITIONS)// N PLAN REVIEWERS NAME Illllilllllllllillll 11111 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." / _ APPLICANT'S SIGNATURE: TITLE LADATE f 0I 'S'Q3 Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minima installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name L.LN L Mai ting Address 7�'� -AST 1��1`L-, � .0 ,ea,)t 104 Day Phone Number Signature \ Date 17 S" 3 EH 23 008 (Rev 1/7/92) WP 3