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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 BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-END 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 # PROJECT CONTACT 8 TELEPHONE # Stephen Kirk (425) 251-6222 <br /> F FACILITY NAME ARCO AM/PM Mini-Market I PHONE # <br /> A <br /> C ADDRESS NEC Grant line/POMBO Road (2470 Grant Line Road) 744Cy CA <br /> I <br /> L CROSS STREET Grant Line Road & Pombo Road <br /> I <br /> T OWNER/OPERATOR Atlantic Richfield Company PHONE # <br /> Y (714) 670-5401 <br /> C I CONTRACTOR NAME Unknown at this time. /Will forward PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC # + CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES _ NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # 000506 <br /> R <br /> I i i!l!111111111111111111111111 <br /> TJNK ID # TANK SIZE CHEMICALS TOB STORED PgOPOS€D INSTALLATION <br /> 39- .�p�-4q-+ 20,000 Gal. Reg. Unleaded 9/1/96ATE <br /> T 39-:_ rrrsae-'a„Y „nl aadPd!r,l:rPm <br /> A 39 Gq uklteo-Ar CA P i q <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTAC MENT WITH CONDITIONS) �/Iq <br /> N PLAN REVIEWERS NAME bS\�� DATE (S I4 7- <br /> Fiiiiiiiiiiiiiiiiiiiiiilill II 111111 I II 1111!1111111111lIIl1111llllllitllllllllillil111111f-11111111111111111111111111111 <br /> PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANO REGULATIONS OF <br /> N JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> E 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 ATS? <br /> : 7aSCi./T�7/G�� DATE <br /> Indicate the responsible party to be billed for additional PHS-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 ENVIRONMENTAL HEALTH DIVISION <br /> 304 BWeber Amp. ;;-E' F-'___ <br /> P O. Box 388, Stockton CA 95201-0388 <br /> Mailing Address 18215 72nd Ave. S. Kent A Approved <br /> enie <br /> Day Phone Number 25) 251-6222 <br /> DateA41 �� <br /> Signature <br /> t �* I <br /> EH 23 008 (Rev 12/13/97,—UST Reg's May 5, 1994) <br /> 4 <br />