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SAN JOAQUINPUBLIC <br /> HEALTHHEALTH <br /> DIVISIONRVICES <br /> ENVIRONMENTAL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> KS IS NY " ID FOR THE CALENDARWHICH IT HAS <br /> THE APPLICATION FOR INSTALLATION NEOFUNDERGROUND <br /> NEXT DAR STOYEARAGE TALETTER OISLSENYLTO PHS-EHO REQUESTINGETHISNEXTENSION THIRTYEDAYSSUED. <br /> ;4 A PERMIT MAY BE EXTENDED INTO <br /> EXTENSION MAY BE GRANTED BY PHS-EHD UPON <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR RECEIPT Of THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE # Stephen Kirk (425) 251-6222 <br /> PHONE # <br /> F FACILITY NAME ARCO AM/PM Mini—Market <br /> i A <br /> C ADDRESS NEC Grant line/POMBO Road 2470 Grant Line Road TRACY G�1 <br /> t - <br /> t L CROSS STREET Grant Line Road & PO Road <br /> s [ PHONE # <br /> T OWNER/OPERATOR Atlantic Richfield Company (714) 670-5401 <br /> Y <br /> KK PHONE # <br /> C CONTRACTOR NAME Unknown at this time. /Will forward <br /> 0. CA LIC # CLASS <br /> q N CONTRACTOR ADDRESS <br /> T WORK.COMP.# <br /> R HAZARDOUS WASTE CERTIFIED YES NO �� <br /> i C PERMIT # <br /> °FIRE DISTRICT • " �� <br /> 0 BOARD OF EQUALIZATION # 000506 gg� <br /> I R <br /> I I I I I I I I I I I I I I I I I I I I I i I 1 I l I 111 TANK t zE ° , P�°/ INSTALLATION <br /> TANK ID # <br /> 39 1 20,000 Gaf. Posuwrilp <br /> 9 97 <br /> � T <br /> e <br /> A 39- <br /> ' N 39- - <br /> g ' K 39- <br /> 39- tI1111111Ui11f��� <br /> P APPROVED APPROVED WITH CONDITION(S) <br /> DISAPPROVED $ <br /> 'f L (SEE ATTACHMENT WITH CONDITIONS) <br /> A DATE <br /> N PLAN REVIEWERS NAMEirIONS <br /> IIiIiI <br /> liillllllfilllilllll <br /> APPLICANT MUS? PERFORM ALL EARtSERVICES. OWNERHORALICENSED NCNTY AGENT'S SIGNATURES, STATE CERTIFIESATHE FOLLOWING�RULES ANItRCERTIFY THATT0IN <br /> SAN JOAQUtN COUNTY PUBLIC HEALTH <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, [ 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 FOLLOWINGt <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEP.MIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> TITLE DATE <br /> APPLICANT'S SIGNATURE: <br /> DATE <br /> Itati <br /> insta <br /> our <br /> ini <br /> Indicate the responsible party to bbilled <br /> ls responsfor bilityaforHtheNadditional billpng by signaturestaff time exended beyondealxlhdatembelou on <br /> payment. The party must acknowledge <br /> Name Barghausen Consulting Engineers / Stephen Kirk <br /> Mailing Address <br /> !i <br /> Day Phone Neer 25) 251-6222 <br /> Date <br /> Signature <br /> EH 23 008 (Rev 12/13/ ST Reg's May 5, 1994) ' <br /> Q , <br />