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• M SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES FILE COPY 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 staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name Vfge.0 L*-�Q I Mailing Address Day Phone Number,) !E16 -7/2d Si ature 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) 4 Dat 9521 EPA SITE # PROJECT CONTACT & TELEPHONE # 2J i F FACILITY NAME s ' �u PHONE # A CADDRESS I L CROSS STREET- -�6hWAq9 I- T OWNER/OPERATOR PHO # Y 900 C CONTRACTOR NAME PHONE # qj 2 `L 0 N CONTRACTOR ADDRESSl3w CA LIC # .1-7-1 G.Z g CLASS R HAZARDOUS WASTE CERTIFIED YES �/ NO > WORK.. COMP.# A C FIRE DISTRICT VAV'if '� t ,CL_ PERMIT # T - 0 BOARD OF EQUALIZATION # R TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION 39 DATE T 39- A 39- N 39- K 39- 39- 39- P L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME IIII1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 DATE 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: yy��%% TITLE �%LU�4—� AW4 ATE Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name Vfge.0 L*-�Q I Mailing Address Day Phone Number,) !E16 -7/2d Si ature 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) 4 Dat 9521