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U • 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 -£HO REQUESTING THIS EXTENSION THIRTY DAYS 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. DO NOT WRITE IN ANY SHADED AREAS. Indicate the responsible party to be billed for additional PHS-EHD staff time expenoeo Deyona the o noun mirmimu -•-•• payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name C1-�1�fZA-N Jii T ZesJy-r(.r Mailing Address 00 TA 2 'V Vlot_---- Day Phone Number 15 � O -i a r Signature EH 23 008 (Rev /95, s May 5, 4 Date -24l)- 09 EPA SITE # i�j��LF=- I PROJECT CONTACT & TELEPHONE # f4 (KE LEt E W/k(_TaJ tom& �,3l.,v j /-5 -) i F PHONE FACILITY NAME'['-7,?pci T -F , �'t r� SCJ C Q ADDRESS 5-31 w, rzP, TQ G G� ( S� T (a I L CROSS STREET 1 I T PHONE ` OWNER/OPERATOR - C �( to (-t)"-j , -T SV Z t Y C CONTRACTOR NAME Nj&j INC, I PHONE # I 1N{�LT�r.. `�+j[o!ti �v2j r 0 NCONTRACTOR ADDRESS P, D, eo)� (07S W• Sr,cc�Mtti` CA LIC # jG(-4 - 3g CLASS jA 13, K•� z S6=( f T R HAZARDOUS WASTE CERTIFIED YES K NO EK WORK.COMP.# NwC ¢$21+ 3o-Oo IZ•ir 18 A C PERMIT FIRE DISTRICT :'("ry tJT= -''r2.kl�,y r 0 BOARD OF EQUALIZATION R 1111111111 TANK llllillllllllt TANK [D # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION S 2,� 39- 2y> C�Co If Se "; T A 39- 70F 000 ► L 39- 1 oo0 JN L N 39- A- K 39- 39- 39- P L ! 111 APYJOVED APPROVED WITH CONDITION(S) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME 144M DATE itiilllilllllllllll! I I illi 1 11111111 1 11111111 II I 1111 11 illllllllllllllllllllillillllll IIIII1111111111' 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 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I 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 CALIFORN ." LT -d APPLICANT'S SIGNATURE T ITLE PSA NfaCR DATE Indicate the responsible party to be billed for additional PHS-EHD staff time expenoeo Deyona the o noun mirmimu -•-•• payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name C1-�1�fZA-N Jii T ZesJy-r(.r Mailing Address 00 TA 2 'V Vlot_---- Day Phone Number 15 � O -i a r Signature EH 23 008 (Rev /95, s May 5, 4 Date -24l)- 09