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r• <br /> er <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE 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-EHO 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 /> 00 NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE x PROJECT CONTACT & TELEPHONE S Stephen Kirk (425) 251-6222 <br /> F FACILITY NAME ARCO AM/PM Mini-Market PHONE X <br /> A <br /> C ADDRESS NEC Grant line/POMBO RoadC2-Z25 1'vc'5' 4co�v7'41,V,, 7ZW C4 -7.5-3-;yo, <br /> t _ <br /> L CROSS STREET Grant Line Road & Pombo Road <br /> t <br /> T OWNER/OPERATOR Atlantic Richfield Company PHONE ;VY (714) 670-5401 <br /> C CONTRACTOR NAME f"/�j�j�Cj� c�;.� �T�, PHONE � g`�, �Z- j- <br /> N CONTRACTOR ADDRESS ..�� 9 CA LIC 0 /7 7`"Z:0 CLASS 48 $r tMZ <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YESX_ NO WORK.COMP.A A/97,4 /47?/9 <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 80ARD OF EQUALIZATION 9 000506 <br /> R <br /> 'I!!!lltltl111111.111i11l1tllll <br /> T NK ID TANK SIZE CHEMICALS TO 8 STORED PQnOARF� INSTALLATION <br /> 39. 20,000:Gal. . Reg. Un eaded S �3TE <br /> T 39- JZ.�Or fs°/tL 5t./jj112d�1A t/e-/�� <br /> A 39- /' M Ei'.92. .EE9- 4NGe*-Umo <br /> N 39- <br /> K 39- <br /> 39- <br /> 39-fill 1111111111111 11111111111119111 11V III fill �J <br /> L _ l' � IIIIIIIIIIIIIIIIIIIII <br /> APPP,ROVED APPROVED WITH ONOI I N(S) _ 0 SAPPROVED �^'^ ^� Q <br /> A --C/� <SEE ATTACHMENT WITH CONDITIONS) J O ' ! <br /> N PLAN REVIEWERS NAME GATE <br /> I1lltillltllllllttlltl I .111!11! ! illtlliil 1!11!1 111lI!!Il1111t tilt! Clilitll 1 lllitllll 1 1 11!!1 Iltiltltll!lllt <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 PERSON IN SUCH A MANNER AS TO BECOME <br /> 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 CALIFORNIA." <br /> APPLICANT'S SIGNATURE: �� TITLE �l�c7h?EStT/T/17Jllc DATE , _ <br /> Indicate the responsible party to be billed for additional PNS-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 Barghausen Consulting Engineers / Stephen Kirk <br /> Mailing Address 18215 72nd Ave S Kent WA <br /> Day . :lone Number (425) 251-6222 <br /> Signature Date <br /> -H 23 008 (Rev 12/13/95, UST Reg's May 5, 1 <br /> t <br /> �r <br />