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SAN ,J AQUIN COUNTY PUBLIC HEALTH SERVICES <br />"\` ENVIRONMENTAL HEALTH DIVISION <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 ISSUED. <br />A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS -END UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name P 1-1 L Pebi!a r1 6rou p, Inc.. <br />Mailing Address 6,50 Howe, Alenue , # -A-1-F i `99Gr3mer)to GIs 958zJ' <br />Day Phone Number (111&) (o4& -400-5 <br />SignaturC/icpwar.✓ <br />EH 23 008'(R v 2/13 , UST Reg's May <br />UST SYSTEM DRAWING INFORMATION <br />El <br />Date +/ 1&zg03 <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE #jam,) SerrCff (1*)&31- 7711 <br />F <br />FACILITY NAME 504AI: na 7 eIeve�n t)tDre Z0&52, <br />PHONE # <br />A <br />C <br />I <br />ADDRESS +&27 C>a Vinci OrlVe, <br />L <br />CROSS STREET March Lane, <br />I <br />YOWNER/OPERATOR <br />ThV ��Ia� r <br />/� tJ t U GprLy r� 1 Or <br />PHONE # /q10 &31-771) <br />1 J <br />C <br />CONTRACTOR NAME _ [,lane �-Ur YBIlOr) <br />PHONE # (5(�Z 595 - 4555 <br />D <br />N <br />T <br />CONTRACTOR ADDRESS 1101 C• Sprin gtrtel- <br />CA LIC # �jS3�33 <br />CLASS A C3 K&V- <br />oz czl GZ7 657 <br />R <br />HAZARDOUS WASTE CERTIFIED YES CK NO <br />WORK.COMP.# w G g179d34�0 <br />A <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />BOARD OF EQUALIZATION # -rY N a 44 - 002 ZS1 <br />R <br />II1111111111llllillllll1111111 <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- DATE <br />T <br />39- <br />A <br />39- �c 3T_ 1 OaG4147n PfGlrlluW! L1nle� 5e_ q <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />IIIII!!l11111111!lllllilllllil � IIIlII1111111 I111� I1111�lllllllllllllilllillilillllllllllliilll IIII11111111111I11111 <br />L <br />APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />N <br />_ <br />(SEE�TACHMENT WITH CONDITIONS) G <br />- <br />PLAN REVIEWERS NAME <br />DATE <br />illllillllllllllllll 111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA.""�, <br />r <br />APPLICANT'S SIGNATURE:, G;;r JO��,+s (of R1iL CL -sign 6!� a e� ITLE f&- �9U&-3 J DATE 4 A% qb <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name P 1-1 L Pebi!a r1 6rou p, Inc.. <br />Mailing Address 6,50 Howe, Alenue , # -A-1-F i `99Gr3mer)to GIs 958zJ' <br />Day Phone Number (111&) (o4& -400-5 <br />SignaturC/icpwar.✓ <br />EH 23 008'(R v 2/13 , UST Reg's May <br />UST SYSTEM DRAWING INFORMATION <br />El <br />Date +/ 1&zg03 <br />