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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br />APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />inaicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimus installation payment. <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />NameMAnSF-"s ,; Vjrg zISC, ')R1fZd <br />Mailing Address_ x.113 IcTp Iii Sr Ti go ri l (a <br />Day Phone Nugkr, a14 9 — '59 C'?S— <br />Signs <br />EH 23 008 (Rev 1/7/92) WP <br />Date I)--9 - %3 <br />EPA SITE # <br />PROJECT CONTACT 8 TELEPHONE #/0eN/}/Lo/49 >7/LTDn/ Say -9653 <br />F <br />A <br />FACILITY NAME ��fJ-S�n/f d(liJ�lS6 ��/(jay <br />PHONE # <br />r209 -s99 -37/s` <br />I <br />ADDRESS 3 9 SO, STDCk I`0 o f S7', 20/60,-! 6AWF• 95366 <br />L <br />CROSS STREETSE !�f-JA S7Yet&7- <br />I <br />T <br />Y <br />OWNER/OPERATOR!� <br />7b73b2T � 0A(L0L YYIAOSbN <br />PHONE # <br />ao9-S`i9- 31-/D5 <br />C <br />CONTRACTOR NAME , J')11 CO <br />PHONE # <br />0 <br />N <br />T <br />�-^ <br />CONTRACTOR ADDRESS /a I7 6v, % �%• )VoQ .7f n <br />n <br />CA LIG # yy9 U 6 t� <br />CLASS ' <br />A <br />R <br />A <br />HAZARDOUS WASTE CERTIFIED YES_ No — <br />WORK.COMP.# pN L6 <br />C <br />FIRE DISTRICT <br />C i7y OF 2/pori <br />PERMIT # <br />T <br />0 <br />BOARD OF EQUALIZATION # <br />R <br />IIIIIIIIIIIIIIIIIIIIIIIIII IIII <br />TANK ID # TANK SIZE CHEMi ALS TO BE STORED PROPOSED INSTALL TION <br />39- .2601) r74L. �2 C) IS L <br />i4R7- DATE - <br />A <br />N <br />39- <br />39- <br />boo GAL <br />a fm, &>4,s <br />K <br />39- <br />39- <br />39- <br />IIII <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />A / (ACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME !L .LL{_ DATE Z-=10 <br />IIIIIIIIIIIIIIIIIIIIIIIIII 1111111 II II I I III IIIII II II IIII � II 111111 IIIII I IIIII Ililll <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: 9 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."LIf�ANIl <br />/ A o <br />APPLICANT'S SIGNATURE: I�$�, w. TITLEYCl, WES SErrlW DATE )1-3-93 <br />inaicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimus installation payment. <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />NameMAnSF-"s ,; Vjrg zISC, ')R1fZd <br />Mailing Address_ x.113 IcTp Iii Sr Ti go ri l (a <br />Day Phone Nugkr, a14 9 — '59 C'?S— <br />Signs <br />EH 23 008 (Rev 1/7/92) WP <br />Date I)--9 - %3 <br />