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ENVIRONMENTAII HFALTH DIVISION APPLICATION FOR UNDERGROLM TANK INSTALLATION PERMIT APPLICATION FOR INSTALLATION OF UNDERGROUND tANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT CAN BE EXTENDED INTO THE NEXT CALENDAR YEAR LF A LETTER IS SENT TO PNS -END REQUESTING TNIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- OW 1101 OtTENSION NAY BE RkANM BY PNS -END UPON RECEIPT OF THIS LETTER. DO NOT WRITE 19 ANY SHADED AREAS. rnr�rlrrrrrrrrrrr�i,��rrrirrrrr TANK IO TANK 512E CHEMICALS TO BE STORED PROPOSED INSTALLATION 34- 17—, o c2 O DATE T 39- A 39- 7 7-77 —T N 39- K 39- 39- 39- rrrr P L_ APPROVED APP1040 uttN owitt(w(s) 019ANMKM , A (SEE ATTAC*Ot WttN CMITIONS) N PLAN REVIEWERS MALE DATE urarrrrrrrrr�rrrrr rrrrr APPLICANT MRDST PERFORM ALL WORK IN ACCORbANCE WITH SAN JMWIN Ct`1lN" ORDINANCES, StAtt LAWS, ADD RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LIQ AGENT'S SIONATURE CERTIFIES THE FOLLOWING% "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR UNICH THIS PERMIT IS ISSM, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAYS OF CALIFORNIA." CONTRACTOR'S MIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 1051IE0, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION NWS OF CALIFORNIA." APPLICANT'S SIGNATURE: ZL TITLE ' SjUA 6s1 7X_ . DATE V -2 -2 -?Z EN 23 000 (Rev 1/7/92) WP Pip! 3 PA YMEI F RECEIVED JUN 0 5 19v92 Surd JOAQUM t:0' )RITY PUE31_IC; NEALI11 SEl'VlC':S F-MVIRONMENI AL HUll-I N CIViSIn 3 EPA SITE PROJECT CONTACT A TELEPHONE / A FACILITY NAM C I Awn" 3330 ti, �t� ,& r S o c r L I CROlN BtREET L E — C LAJ . T Y�cn/� OUKO/OPERAtOR / �6,11w4 �.s'r-v_0c.. PHONE # 2-0P'.-9 9 Y -7Z25— CC CONTRACTOR NMN: S f /ESSC d A.) S r -;Q U C - T-1 C) PHONE N T CONTRACTOR ADDRESS �O ,� ©x Z 8 Y 9 IW l l 4 CA LIC # 333 S' 9 CLASS R A HAZARDOUS WASTE CERTIFIED YEs-a- NO C FIRE DISTRICT PERMIT # T 0 BOARD OF E UALt AMW # R rnr�rlrrrrrrrrrrr�i,��rrrirrrrr TANK IO TANK 512E CHEMICALS TO BE STORED PROPOSED INSTALLATION 34- 17—, o c2 O DATE T 39- A 39- 7 7-77 —T N 39- K 39- 39- 39- rrrr P L_ APPROVED APP1040 uttN owitt(w(s) 019ANMKM , A (SEE ATTAC*Ot WttN CMITIONS) N PLAN REVIEWERS MALE DATE urarrrrrrrrr�rrrrr rrrrr APPLICANT MRDST PERFORM ALL WORK IN ACCORbANCE WITH SAN JMWIN Ct`1lN" ORDINANCES, StAtt LAWS, ADD RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LIQ AGENT'S SIONATURE CERTIFIES THE FOLLOWING% "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR UNICH THIS PERMIT IS ISSM, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAYS OF CALIFORNIA." CONTRACTOR'S MIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 1051IE0, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION NWS OF CALIFORNIA." APPLICANT'S SIGNATURE: ZL TITLE ' SjUA 6s1 7X_ . DATE V -2 -2 -?Z EN 23 000 (Rev 1/7/92) WP Pip! 3 PA YMEI F RECEIVED JUN 0 5 19v92 Surd JOAQUM t:0' )RITY PUE31_IC; NEALI11 SEl'VlC':S F-MVIRONMENI AL HUll-I N CIViSIn 3