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A <br />i <br />L <br />1 <br />T <br />Y <br />v <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br />'HE APPLICATICH FCR INSTALLATION OF UNDERG20UND STORAGE TANKS IS ONLY VALID FCR THE CALr--NDAR YEAR IN WHICH IT HAS SE=N ISSi:EC <br />A PERMIT .MAY 3E EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS- RECUESTING THIS EXTENSION THIRTY OATS <br />PRICR TO THE ENO OF THE CALENDAR YEAR. A ONE TIME, ONE TEAR EXTENSION WAY BE GRANTED 3Y PHS -:HD UPON RECEIPT OF THIS LETTER, <br />00 NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE 4 PROJECT CONTACT b TEL PHONE S`' <br />MiaLE6a ��� ���aroti��•i�o� <br />-Ac <br />IL 1 T Y NAMEt r1PHONE <br />ADDRESS j L plf-CA izp.► Q GY G�' <br />CROSS STREET 1 <br />i v <br />OWNER/CPERATCR <br />C i(r <br />J `! i' ( /A; I PHONE # <br />io <br />C CCNTRACTCR NAME �NiL�,T�r % NJ&;Nt-,Q� <br />0 - <br />N I CCNTRACTCR ADDRESS P Q, 60),. 10' 7 AN • Sr Gal. <br />R ` HAZAROCUS WASTE CERTIFIE] YES X MC— <br />A-' <br />PHONE <br />CA LIC 2 <br />'5 ; - 8��c <br />.i 3 389 <br />CLASS /A <br />WCRK_C:iHP.A NwC q$2�•3o-Do—e�— <br />C i FIRE DISTRICT Tj Ax C, - gzr%; " <br />30AR0 OF ECUALIZATiCN N m -r- +4— ,. O3 z70S <br />I 39- <br />T 39- <br />' <br />v <br />39- <br />39- <br />39- <br />39- <br />ti <br />9-39- <br />39- <br />F <br />tlttlll!(tltt(tltflllifttf <br />TANK IO ? <br />1 <br />TANK SIZE (,!sstiL LaaS� CAEMICALS TO 3E STORED <br />1655(.. <br />20. coo tJr�=Sc C. <br />PROPOSED IHSTALLATiC <br />S AT: �as <br />� .• <br />1 1 <br />tl'Y't T17TT' <br />J.44 <br />APPR APPROVED WITH CONOITICN(S) _ i?iSAPPROVEO <br />Sc'E ATTACHMENT WITH CCNOITIOMS) <br />?LAN REVIEWERS NAME DATE <br />ttftttltfitlfftttllfttfttltUFl- <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN .0=19 COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOACUtN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 01 CERTIFY THAT IN g <br />I THE PERFCRMANC= OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO SEC^ME <br />SUBJECT TO UCRKER'S CCMPENSATICH LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCGITRACTING SIGNATURE CERTIFIES THE FOLLOWING <br />'I CERTIFY THAT IN THE PERFCRMAN=- OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL E4PL0Y PERSONS SUBJECT TC WORKER'S <br />COMPENSATION LAWS OF CALlFORN .m <br />pRc DE'P'T I <br />APPLICANT'S SIGNATURE TITLE MA tV�*' G �, Wf{ L7 od OATS <br />t <br />Indicate the responsible party to be billed for additional PHS-EHO staff time expended beyond the 8 hour minimum installation <br />i <br />payment. The party must acknowledge this responsibility for the additional bitting by signature and date below. <br />Name G HAl2v4-h+ ::Tt T 3 v TLr1r <br />Mai 1 ing Address_ x'00 TA GF"FM49Y47 � 64 3 <br />Day Phone Number S $ O <br />signature___ -_L_ <br />eH 23 008 (Rev 12/1 <br />UST Reg's May 5, 1994) <br />El <br />Date 2. <br />