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0 <br />i <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN <br />ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY <br />DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS <br />LETTER. <br />PROJECT CONTACT: M C A a E L WA t,' — �( <br />CONTACT PHONE # 9'16 _ -3- P s' <br />FACILITY NAME: F2 E YA 0 t -L T S IJrG- L L <br />FACILITY PHONE# 2 Oct _ 9 t,// V:� 411 <br />FACILITY ADDRESS: Z41'4 r= - F2 e 1% 0 u.T- 5t— <br />S:T-0C,X roN CA QS'205- <br />CROSS STREET: N FI L 6 c.tir s T - <br />OWNER/OPERATOR: M 1 c a A -M, -L "bO OK 1 K C, v e l- <br />PHONE: Z o y_ qte <br />CONTRACTOR NAME: u/A L TO K( E nt C. 19 F -F- R144C, <br />PHONE: g16 - 3 :� 3 _ / I ,s L - <br />CONTRACTOR ADDRESS: ?,0, 3'1y, f ° Z s- <br />W S A-t�n r C A 9 S-6 R <br />CA LICENSE # <br />HAZARDOUS WASTE CERTIFICATE: ES NO <br />WORKERS COMP # } 13 q I - — } 0 { <br />FIRE DISTRICT: City O F ST0 C is TO r -I <br />PERMIT # <br />BOARD OF EQUALIZATION # <br />TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br />01 /s 00 0 'asool'te <br />- s*4 S- 112 10S - <br />o t, '(0, 0 o C, A-30 L r M K.. <br />- Of k <br />❑ APPROVED ❑ APPROVED WITH CONDITIONS ❑ DISAPPROVED <br />(see attachments) <br />PLAN REVIEWER'S NAME DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN UUUN I UKU1NANt-hN, S lA 11~. LA W J, <br />RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br />SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECT TO WORKER'S COMPETISATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE <br />TITLE C o ►,L T- 2 p-c.T 0 2 DATE T- <br />Z o s - <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 -hour <br />minimum installation payment. The party must acknowledge this responsibility for the additional billing <br />by signature and date below. <br />Name k/ A L 1 0 4 T�- C - <br />Mailing Address <br />/0 z S - <br />Signature r "-4 —" <br />C. REQUIRED SUBMITTALS <br />-3- <br />Date S- �-Z- /0 s- <br />(` A 9s-69( <br />Daytime Phone 9(6 - 31+3 - It S *L-- <br />