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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 3E EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD 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 UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE 4 PROJECT CONTACT & TELEPHONE ;* Stephen Kirk (425) 251-6222 <br /> F FACILITY NAME ARCO AM/PM Mini-Market PHONE 9 <br /> A <br /> C ADDRESS NEC Grant line/POMBO Road (2470 Grant Line Road) 7,24,--y CA <br /> t <br /> L CROSS STREET Grant Line Road & Pombo Road I <br /> I <br /> T OWNER/OPERATOR Atlantic Richfield Company PHONE 4 <br /> IY (714) 670-5401 <br /> C CONTRACTOR NAME Unknown at this time. /Will forward I PHONE <br /> 0 ' <br /> N ( CONTRACTOR ADDRESS CA LIC 9 i CLASS <br /> T <br /> R j HAZARDOUS WASTE CERTIFIED YES X NO WCRK.CCMP.; ` <br /> A <br /> IC I FIRE DISTRICT I PERMIT 4 i <br /> T <br /> R i BOARD OF EQUALIZATION 4 000506 <br /> 1i1111111lI1l1111i111i11111111 <br /> TANK ID 4 TANK SIZE CHEMICALS TO 8 STORED PgOPOS'D INSTALLATION <br /> 39- .501 g 4- 20,000 Gal. Reg. Unleaded 9/1 f 9dATE <br /> T 39-�{- : inl ad dorm 9/1/97 <br /> N 39- <br /> K <br /> 9 K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39-P <br /> L APPROVED �'� APPROV D WITH CONDITIONS) _ DISAPPROVED <br /> ASE E A TAC ENT WITH CONDITIONS) <br /> I N PLAN REVIEWERS NAME v C DATE cs Aq �--7— <br /> 111111111111111111111111111 1111111 1 11 1111111l11!ll1111111!1111ii1111!llili111111111111111 1111 1!llllllilllllllllll <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 /> j 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 '.IORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: / �Z— TITLE APA4i2L+an w A – DATE <br /> Indicate the responsible party to be billed for additional PHS-EH <br /> �p"t��j@N minimum installation <br /> payment. The party must acknowledge this responsibility for the f SIM <br /> and date below. <br /> Bar hausen Consultin En ineers / Ste he ionPA 95 <br /> Name g g Engineers P z$ox 388, Stockton CA 95201-0388 <br /> Approved 14 <br /> Mailing Address 18 215 72nd Ave_. S. Kent, WA Qknie�[] <br /> Day Phone .Number (_425) 251-6222 / <br /> SignatureLz==)_ 0 `�/ <br /> EH 23 008 (Rev 12/13/ UST Reg's May 5, 1944) L t F— <br /> 4 <br />