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Y 7-38-1998 2.31PM FRr-% • P.5 <br />f <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 -END 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-E'HO// UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. 141A611•P N /i i , / <br />EPA SITE S <br />PROJECT CONTACT b TELEPHONE # Z�eS!• /✓ D <br />F FACILITY NAMEC �vRD <br />A <br />PHONE # %(Q� <br />C ADDRESS <br />I <br />L CROSS STREET L <br />T OWNER/OPERATOR nr� 9Q�UG� ,a <br />PHONE r,��` <br />C CONTRACTOR NAME �A/b 90 AI.S O s G 0V <br />'Y <br />PHONE # ,C 7 _ U <br />0 <br />N CONTRACTOR ADDRESSZhf„ ice, �C e ^�Ii s� <br />T �w Y <br />CA LIC # -7 <br />CLASS <br />�! r7 <br />R HAZARDOUS WASTE CERTIFIED YES NO <br />Camp it <br />A <br />C FIRE DISTRICT <br />PERMIT S <br />T <br />0 BOARD OF EQUALIZATION # <br />R <br />Itlllllllllltillllililltiillli <br />A ID # TANK SIZE CHEMICALS TO BE STORED P SED INSTALLATION <br />39- 0 O DATE <br />T 39- C()4 9- 061 <br />/ p(1 <br />(JNA oI it Se li K P <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39 - <br />Illi <br />P <br />L APPROVED WITH CONDITIONS) DISAPPROVED <br />"APPROV <br />A(SE£ A HMENT WITH CONDITIONS)L? �jfN <br />0 l(J <br />PLAN REVIEWERS NAME DATE <br />t 111111111 11111111m][1111111 IIfl1 1 t IIIIFITITIIII III In 1 til <br />APPLICANT MUST PERFORM ALL YORK 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." f <br />APPLICANT'S SIGNATURE: • TITLE t( 7a 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 acknouledthis responsibility for the additional billing by signature and date below. <br />�t4JA' g�j / /moi w- �i�%ai M �I�rJdP /A/C - <br />Mailing Address <br />�f <br />Day Phone Number 7v 1 <br />Signature <br />EH 23 008 (Rev T21134-99/LMT Reg' sFfty 5, <br />A <br />