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SAN *QUIN COUNTY PUBLIC HEALTH S&ICES NVIRONMENTAL HEALTH OIVISIOR- APPLICATION FOR NSTALLATION PERMIT Pc5p6"tJ2- " * 6 P— 99/1. (— THE APPLICATION FOR INSTALLATION OF UNDERGROOND STORAGE TANKS IS ONLY VALID FOR THE CA NDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PH END RE STING THIS EXTENSION THIRTY DAYS 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. DO NOT WRITE IN ANY SHADED AREAS. / EPA SITE # PROJECT CONTACT 8 TELEPHONE # bio 0-1 r l��v Euial F FACILITY NAME V PHONE A # �r� Cee, VJ tr C ADDRESS 61 ` I L CROSS STREET I T OWNER/OPERATOR �j /n off/ t PHONE # 5( 0) i Y � CCONTRACTOR NAME G PHONE # 7711 &6 0 N CONTRACTOR ADDRESS =CA # CLASS R HAZARDOUS WASTE CER IFIED YES NO A WORK.COMP.#u v(/ C FIRE DISTRICT PERMIT # T 0 BOARD OF EQUALIZATION # R 111111111111111111111111111111 TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION 39- DATE T 39- A 39- N 39- K 39- 39- 39- P 1111 1 1 1 1 ffI I I I I I I I I I I I I I I I I I I I I 1 I I I I I I I I I I I I I I I I I I I I i I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I III I 11 111111 L APPRQYED APPROVED WITH CONDITION(S) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE9-/9 -92 9 11111111111111111111ininnninnillifflinin APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER 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 PERF CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIF ." � d / APPLICANT'S SIGNATURE: TITLE 1 i DATE !� Indicate the responsiblepr ty be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. The pa t awfbdge this responsibility fQr the additional billing by signature and date below. Name 1L G JMoMailing Address Al U 1'� 4I b q I Day Phone Number ' 1` Signature A= Date EH 23 008 (Rev 12/ 5, Reg's May 5, 1994) UST SYSTEM DRAWIN INFOR TIONt,Y�� ;/KK OF--f�hS COAjjM0�S 4 ,