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v (' a r ENVIRONMENTAL HEALTH Dl N APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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 1S SENT TO PHS -EMD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION KAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. TANK 1{ftflttfllltltlil{Illlf / TANK 1D # TANK SIZE CHEMICALS 70 BE aiUncu rWrUbtV 1NNi LtnilON 39- %CMZ 7 12".000 40A cTop- VIHIQA r:L& , - DATE T 39- -- J Z. G A1� HoT®R OHIO& FQELd -";-74- A 39- .� [SALE �iC"'[QP V)q IC1__,L rug N 39- K 39- 39- Iltt I P L _- APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED E ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME G DATE 1TrV'TT•I•(Till-iTiTl 11 l l l I I I I I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CER7IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL NOT EMPLOY ANY PERSON IN SUCH A KANNER 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 CALIFGRNIA." APPLICANT'S SIGNATURE: TITLE JO- DATE —W3 Ira indicate the responsible party to be billet for amitionat PHs-tnu staTT time ezpenoea veyona cne o nuur 11mils.." V_,..._.___ The party must acknowledge this responsibility for the additional billing by signature and date below. Nailing Address.._-4-2— Day P' Signa EH 23 008 (Rev 1/7/92) WP 3 EPA SITE # PROJECT CONTACT i( TELEPHONE # Qf'ATFA �fiiOWG'IUYC`cI-i - F FACILITY NAME k4%IET4i 6EIs1r cKro /f;�Op PHONE # Zol - -33 _ 1 -7 A C nf ADDRESS "!�(o 50 pRTH I L CROSS STREET Gp 1 T OWNER/OPERATOR PHONE # �j (O ) gC}-� -9551 Y G H O 12.0 5A izb tJG'i 60, is 5 20 9 - a, 3 -I -i C CONTRACTOR NAME O — �cvz 5 o q q') •--- N CONTRACTOR ADDRESS % C)QC CA LIC # f a O _, �j C - q Z• T�i R HAZARDOUS WASTE CERTIFIED YES NO lU� e Q7JC� A C FIRE DISTRICT o 6Oµ+. �J T 0BOARD OF EQUALIZATION # T � / 1 I 3 " , R TANK 1{ftflttfllltltlil{Illlf / TANK 1D # TANK SIZE CHEMICALS 70 BE aiUncu rWrUbtV 1NNi LtnilON 39- %CMZ 7 12".000 40A cTop- VIHIQA r:L& , - DATE T 39- -- J Z. G A1� HoT®R OHIO& FQELd -";-74- A 39- .� [SALE �iC"'[QP V)q IC1__,L rug N 39- K 39- 39- Iltt I P L _- APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED E ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME G DATE 1TrV'TT•I•(Till-iTiTl 11 l l l I I I I I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CER7IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL NOT EMPLOY ANY PERSON IN SUCH A KANNER 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 CALIFGRNIA." APPLICANT'S SIGNATURE: TITLE JO- DATE —W3 Ira indicate the responsible party to be billet for amitionat PHs-tnu staTT time ezpenoea veyona cne o nuur 11mils.." V_,..._.___ The party must acknowledge this responsibility for the additional billing by signature and date below. Nailing Address.._-4-2— Day P' Signa EH 23 008 (Rev 1/7/92) WP 3