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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 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 ISSUED- <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHO REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHO UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT L TELEPHONE # <br /> F FACILITY NAME G;=N PHONE <br /> A #,;1 09_ 4/3 p// <br /> C ADDRESS D/1 �y <br /> I <br /> L CROSS STREET Cfj piTCr UR- <br /> T OWNER/OPERATOR/ m /q H �AJ p PHONE O�_ gy3 <br /> 7 Y � G7 <br /> C CONTRACTOR NAME fir/ >Or (✓I /1 PHONE # 9// _ G.3'1_ l6 y6 <br /> 0 �7 (A <br /> N CONTRACTOR ADDRESS a Idm 4 (.r.., SCA LIC # S9a o/ O ( CLASS�Qy N <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES_ NO �+o�d C✓q WORK.COMP-'. <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION 9 <br /> R <br /> TANK 10 # TANK SIZE , CHE ICALS T BE STORED / PR INSTALLATION <br /> 39- e?10-00 / (i//VLfH � DATE 47 <br /> T 39- 00 O c 7 <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <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: "I 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." <br /> e/ >. py 4 - /7 P <br /> APPLICANT'S SIGNATURE /T( /�� <br /> ��'1/N->`Zm �'+`--DATE b -z f/ <br /> Indicate the responsible party to be billed for additional PHS-END staff time expended beyond the 8 hour minimum installation <br /> payment. The party mist acknowledges tthissresponsibility for the additional billing by signature and date below. <br /> Name */a <br /> Mai ling Address z / 9/^ pAl.*-v % �Y/ IJ-�, �',�pt_{� y (�!g 4sao 6 <br /> Day Phone Number_ 11) 0 1 - 7 513 - ";1-� p� / q <br /> Signatur �-"r' - U��sN" `<<k^/�/�jO Date CJ --z—< 7 <br /> EH 23 008r(Rev 12/13/95, UST Reg's May 7994) ✓^�� <br /> 4 <br />