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•0 ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. PROJECT CONTACT: CONTACT PHONE # FACILITY NAME: FACILITY PHONE# FACILITY ADDRESS: CROSS STREET: OWNER/OPERATOR: PHONE: CONTRACTOR NAME: PHONE: CONTRACTOR ADDRESS: CA LICENSE # HAZARDOUS WASTE CERTIFICATE: YES NO WORKERS COMP # FIRE DISTRICT: PERMIT # BOARD OF EQUALIZATION # TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE ❑ APPROVED PLAN REVIEWER'S NAME ❑ APPROVED WITH CONDITIONS ❑ DISAPPROVED (see attachments) DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" Applicant's Signature Title Date Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 -hour minimum installation payment. The party must acknowledge this responsibility for the additional billing by signature and date below. Name Mailing Address Signature Revised 813107 Date Daytime Phone