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• ~ ' f "torr�zv®m+c NT`w <br /> - kJ D <br /> JSAN JOAQUIN COUNTY PUBLIC HEALTH SERV CES <br /> ENVIRONMENTAL HEALTH DIVISION SEP a 4 1996 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMj�� <br /> F�IVfROO�NAA��MENTAL H S n <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENI��tVEY11f M IT HAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHO 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-EHD UPOW RECEIPT OF THIS. LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. / <br /> EPA SITE # G A / o 0 0 3 3 3 8 PROJECT CONTACT & TELEPHONE # m/k c Z t Gf 3-�L 3 —112 6 <br /> F FACILITY NAME (✓ S O # a 0 PHONE a y 718 _ -7 1y 9 <br /> A <br /> ADDRESS <br /> 1 93 a QV, O h d <br /> I <br /> L CROSS STREET <br /> T OWNER/OPERATOR PHONE # <br /> Y r s h G f /SIO 6S :P- - S o 0 <br /> C CONTRACTOR NAMEi 2i•� Z n C PHONE # 9 S <br /> 0 <br /> N CONTRACTOR ADDRESS P O 0,Y-0 3- S' CA LIC # ( CLASS <br /> T v C <br /> R HAZARDOUS WASTE CERTIFIED YESL.X, NO I WORK.COMP.#yVG <br /> A <br /> C FIRE DISTRICT /��/ b F c _ F • I PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # ••1.. O J <br /> R U\,% I <br /> !1!lilltilll!!!I!I!1l1111l111! <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORE'S PROPOSED INSTALLATION <br /> 39- �-� v t 1 <br /> DATE95 ga <br /> T 39- r / f <. 2r /51 Z <br /> A 39- ; <br /> 1 N 39- <br /> I K 39- r <br /> 39- <br /> 39- ny� / <br /> !!!! IJ Y11 111111111111 <br /> P <br /> L _ APPROVED APPROV WITH CCNDITION(S) DISAPPROVED <br /> A (SEE ATTAC--ENT WITH CONDITIONS) �G. <br /> N PLAN REVIEWERS NAME $' ( n DATE <br /> tltitltilillttitititlll lill1111111111 lillitliltlll! 1111111! llllllill! 1111111111111111111111111111111111111111111fillllli <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SA 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 I ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNI ." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> I "I CERTIFY THAT IN,;HE PER RMAN 0 THE WORK FO WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALI 0 NIA. q n r <br /> APPLICANT'S SIGNATU E: TITLE rnG�" - DATE .& 4_u Ga `fr, <br /> Indicate the responsible party to be bitted f r addizional PHS-EHO 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 A-f�/� /Yi1/le k-o2U�/o7` — �7�i•/C Soo /17.�/'�Ge7�S �/�G <br /> Mailing Address P• b . BOX 5 4/S F2 CMQp 2Z Ca / y5_.3 2L <br /> Day Phone Number 6 - A 50 a <br /> Signatur JL1, Date V�U� ` �O <br /> £H 23 008 5, Ut s May 5, 994) <br />