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a t <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br />7HE 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 ENO OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE » CIA%I PROJECT CONTACT & TELEPHONE + M1Ke;- ( eff-- <br />F I FACILITY NAME CANeIPA'S CAF, W ASH ( PHONE » C!� <br />A CI ADDRESS p <br />-2 y : J 2- <br />L <br />L <br />(� <br />CROSS STREET <br />T OWNER/OPERATOR P40HHE0»p) p� /a t,(0 <br />C CONTRACTOR NAME 5�: I PHONE » �) e C-� - ?) ( O <br />0 <br />NCONTRACTOR ADDRESS �. �- 50X 140 I CA LIC » �23'�jo CLASS A,15,HA:Z. FICA C -i <br />T <br />R HAZARDOUS WASTE CERTIFIED YES 1� NO I WORK.COMP.» SC0011(p(0(00 it <br />A <br />C FIRE DISTRICT L`I-�+cr �- �I•UG`�`��� I PERMIT try PRor,�� <br />T , I <br />0 30ARD OF EQUALIZATION » 't"Y �-I �) �AQ 4+ b2.:+5(00 <br />R <br />�1111lIIIllllll1111lIt1111111!! � I <br />TANK ID » TANK SIZE CHEMICALS TO BE STORED PAGAGGR INSTALLAfiel <br />39-0042311'4301 12, Cc Cy VF.ILQ, SUP. Gam. , DATE <br />T 39- %1 12 . 00 0 piein . v{,—i <br />A 39- 11 . 0:F, 4i 000 'I 9 <br />N 39- �� e 0 h �r�00FJIr-S.«._ C7 - 1-71101 <br />K 39- I OS • l"1" o <br />39- — I <br />111! _ •TTTff ! It•tTfl•i1T <br />P <br />L APPROVED APPROVED WITH CCNDITION(S) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITICNS) <br />N DLAN REVIEWERS NAME DATE <br />1111111111111111111111111111[11111111111111111111111111!1111111111111111111111111111111tltllllttl1111111i11I111i11111 11111 <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 PERSCN IN SUCH A MANNER AS TO BECOME <br />I SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />I "! CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNI " <br />APPLICANT'S SIGNATURE: t/L � TITLE �/tiL✓.��'n DATE IA -.V-60 <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 G i ASN P S CrZ•• v"`! /�. 1� -- — <br />Ma i L;; ng Address ' J v�L� Imo! `yNe ` C -1a '. Cf-, <br />Day Phone ,Number /d-O� - rT 1 (0 h' <br />Signature <br />EH 23 008 (Rev 12/13/95, UST ,leg's,. y 5, <br />D <br />Ln <br />Date /,2-174 6 <br />