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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNMGROUND 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-END 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 /> EPA SITE # QA Q'E>( &��� PROJECT CONTACT L TELEPHONE ; -T`/' �; �•, _,G� cin �('� - ^L i� <br /> F FACILITY NAME � lV� -5 .-L— C, PRONE # <br /> A <br /> C ADDRESS 2�� `t" VAL't- !1 <br /> I <br /> L CROSS STREET <br /> 1 <br /> Y OWNER/OPERATOR _ ` PHONED - `3576 r <br /> L C S 7 b <br /> C CONTRACTOR NAME P0�> ` �( PHONE # _ _ (DDD <br /> 0 I <br /> N CONTRACTOR ADDRESS 1t,z CA LIC # CJ OlO CLASS _L0 L <br /> T l�1.1 <br /> R HAZARDOUS WASTE CERTIFIED YES No WRK.COMP.#u�G3p_ .(J <br /> APERMIT # <br /> C FIRE DISTRICT �Pp <br /> T <br /> 0 BOARD OF EOUAL17ATION # <br /> R <br /> IIIIIIIIIIIIIIIIIIIIIIIIIillll <br /> TTA`NK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> TANK iD # <br /> 39- 50LOOLO � �� .. A _L(" � �-�L(nJ�ij� , 1- DATE <br /> T 39• O 2 SK <br /> DIES -t 1- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9•39- <br /> 39- <br /> P <br /> A➢PROVED APPRO <br /> L VED WIiX CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHN NT WITH CONDITIONS) 3t GN PLAN REVIEWERS NAME lr�. � " 1, 0DATE _1 <br /> IIIIIIIIIIIIIIIIIIII I II h. IIIIII <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER DR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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 PERFDRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE N.-L �`-'w1 TITLE J' nr nj K(L/i_7TQ 95ATE /-0 <br /> /112 <br /> Indicate the responsible party to be billed for additional PHS-END staff time expended beyond the 8 hour minimum installation payment. <br /> The party mist acknowledge this responsibility for the additional bilLing by signature and date below. <br /> Name -T H" L-���i��.,,.�r��I"1 A4 141/0 !/Lt/9f2� I�AI�2N - <br /> Mailing Address 1 ( -22-1 "�^�I vi �AAI- <br /> ✓ �'Z-�-- L�� <br /> Day Phone Number <br /> Signature Date �1 e <br /> EH 23 008 (Rev 1/7/92) WP <br /> 3 <br />