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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 <br />ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY <br />DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS <br />LETTER. <br />PROJECT CONTACT- <br />I <br />CONTACT ONE # <br />j _ 2z- SS <br />FACILIT NAME:FACILITY�P <br />-re E71 <br />-I .NE# <br />FACoILIT ADDReSIK ESS: 'MCI, ST01 TRA <br />CR S,MtL-e1E�t> <br />OWNER/OPER, TOR: <br />PHONE*,_ 1 D 2-72 <br />CONTRACTOR NAME: I& C�sT <br />PH E:'.�ZA -442-0 <br />CONTRACTO11>S CQprneRD(RESS: <br />l)cF9NS�t�E <br />CA LICENSE # -7Z*S39� <br />HAZARDOUS WASTE CERTIFICATE: <br />QS NO <br />WORKERS COW # <br />FIRE DISTRICT: <br />PERMIT # <br />BOARD OF EQUALIZATION # <br />TANK ID # TANK SIZE <br />CHEMICAL STORED PROPOSED INSTALL DATE <br />j Zp poa <br />'Q 6PASO Lt f4 E ( -Zooib <br />Z Pt 2. 000 <br />OQo <br />Teem aAS<>u "LE '7 ('I Zco6 <br />tZ. '7 r -Zoo6 <br />❑ APPROVED ❑ APPROVED WITH CONDITIONS ❑ DISAPPROVED <br />(see attachments) <br />PLAN REVIEWER'S NAME DATE <br />111T`[. 0 ATL'T A1110 <br />APPLICANT MUST PERFORM ALL WORK 1N ACCORDANCE WITH H SAIN JOAQUIN WUN 1 1 J 1 n 1 A —11 <br />RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br />SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECT TO WORKER'S COMPEN TI N LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE <br />TITLE Abtn cT DATE o 0 <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 -hour <br />minimum installation payment. The party must acknowledge this responsibility for the additional billing <br />by signature and date below. <br />Name <br />Mailing Address <br />Sjgnature <br />C. <br />ALS <br />-3- <br />Date 5 ( to I d!o <br />Daytime Phone 4+30--ZS9-3W5 <br />