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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 THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHO UPON RECEIPT OF THIS-LETTER.. <br /> DO NOT WRITE 1N ANY SHADED AREAS. <br /> EPA. SIT # PROJECT CONTACT L TELEPHONE » L ) �v)�yy��a 69 <br /> F FACILITY NAME �_ l l S•�-nom , 3-� PHONE » <br /> A <br /> C ADDRESS -3 6 0 <br /> I <br /> L CROSS STREET <br /> 1 <br /> YOWNER OPERATOR 11 PHONE <br /> C CONTRACTOR NAME r� yy F� _s PHONE # ��2) <br /> C ri✓1�. l-i <br /> N CONTRACTOR AODRE55 CA LIC » �3j�33 CLASS ► -1 A <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES k NO WORK.COMP.9 G 1 2, �� G <br /> A yy el <br /> 8 )-1 <br /> C FIRE DISTRICT G' 1 O -j-�� PERMIT » <br /> T <br /> 0 BOARD OF EQUALIZATION » <br /> R <br /> Ilillttlltlllltlllilltliltllll <br /> TANK ID » TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- t IDic c in fie..) i 110il DATE <br /> T 39- O o 0 1-3 n-.-�1-ar ✓ +�v�) T! ct^? <br /> A 39- ) 500o n�� v��h�Wit✓ �:�� _1 S �t'l <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 <br /> P <br /> L APPROVED APPROVED WITH CONOITION(S) _ DISAPPROVED <br /> A (SEE,ATTACIiHENT WITH CONDITIONS) <br /> H PLAN REVIEWERS NAME J DATEI <br /> IIII III ! 1111111111111 fill I IIIIIIIIIII ! 1 I! I Ill Ililll l I !t 1 1! <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." r <br /> APPLICANT'S SIGNATURE: TITLE G .�1� }cam DATE <br /> 1 ~ <br /> Indicate the responsible party to be billed for additional PHS-END staff time expended beyond the 8 hour minimum installation <br /> payment. The party midst acknowledge this responsibility for the additional billing by signature and date below. <br /> Name �-)—{ L L7 �S j ! �av�'�^ ,� Y G t t'!'1 L -nL, i-4�:>) m�—�-- <br /> Mailing Address G' ��J )� c v✓ ✓ ��• �-�- O <br /> Day Phone Number ' <br /> Signature_ <br /> Date l ' 4� <br /> EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) <br /> 4 <br />