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03-11-97 11 : 1-7AM FROM VITA TRANS-MCDESTO FIS <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> rhE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID Fan THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. <br /> A PER031 MAY aE EXTENDED INTO THE NFXY CALENDAR YEAR IF A LETTER IS SENT To PNS-END REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TINE, ONE YEAR EXTENSIONN Y BE GRANTED SY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE 1N ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT L-TELEPHONE 0 <br /> F FACILITY NAME <br /> ,or� PHONE # `• <br /> A <br /> C ADDRESS 7t RL454 W k4JkEF . <br /> I <br /> L CROSS STREETW. Wky <br /> I <br /> T OWNER/CPERATCR PHONE <br /> Y pe-Tli LJl C.7 1. Z•�-. �'�' <br /> C CONTRACTOR NAME PHONE M CJ J G , X.3( � 1 G+4G <br /> N CONTRACTOR ADDRESS((V[7 Cplcw*a ice., �tN�p WNi G LIC N � .t.7I <br /> R HAZARDOUS WASTE CERTIFIED N0 WORK.COW-9 <br /> A <br /> C MIRE DISTRICT PERMIT # <br /> BOARD OF EQLIALIZATiON S <br /> R <br /> ii�in�tttutnuinttittttttt <br /> 34 TANK '.D # ,00c> Giib!lilC� 8E STORED <br /> PRO?OSEODATE to iaTlawl <br /> xF <br /> T 39- — <br /> A 34- - -- — <br /> N 39- <br /> K 39- <br /> 39- ~_ - <br /> 39- <br /> tt�t <br /> P <br /> L 'APPROIfl1; APPROVED W17H CONDITION($) DISAPPROVED <br /> A / (Srg AYTACHMENT WITH CONDITIONS) -7 <br /> N PLAN REVIEWERS NAPE i� `�--� DATE — I <br /> tttt�i���tttuttttu it` �fi t3ettt <br /> APPLICANT MUST PERFCRM ALL WORK IN ACCC7ROANGt WITM SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND kULES AND REGULATIONS OF <br /> SAN JCAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER 04 LICENSED AGENT'S SIGMA*URE CERTIFIES TxE FMLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OP THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> I SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." =47PACTORiS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES TME FOLLOWING: <br /> "I CERTIFY THAT IN YHE P RFDRMANCE OF THE WORK FOR WMICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWOF CA { ORNI . <br /> APPLICANT'S SIGNATUR TITLE DATE <br /> IndlcATe rho responsipla pare to be1ILed for additional PHS-END staff time expanded beyond the 8 hour minimum fnetalLAtfon <br /> payment. The party must ackno+ edgL& this respansibiLity for the additional billing by signature and date below. <br /> Name kAAfAfW K-A-N V 1 is - <br /> Flailing Addrasa f?fS► . }r � 0+ �� -27G{+�-'�t-� ��J "(�?_�.. <br /> nay Phone N <br /> 9iynaturc Data <br /> EH Z3 OOB (Rev /95, UST Reg's May , <br />