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I`' <br /> 7 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIO n <br /> ENVIRONMENTAL HEALTH DIVISION V <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATIOSgE$MI a <br /> A, p 9 <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CA,L V/pk�QEJI� CH�I HAS BEEN ISSUED. <br /> IRTY DAYS <br /> PRIORIT MAY BE TO THE ENDOFNDED INTO THE CALENDARENEXT YEAR. ALONEATIMEI,BIF A ONE YEARTEXTENSIONIS NMAYOBEHGRANTEDEBYPHS-ERb IJb(8�1 'iE IP1'�OF 7A�5 LETTER. <br /> ✓�CE� <br /> 00 NOT WRITE IN ANY SHADED AREAS. <br /> EPASITE #G•AD 981y591o13 PROJECT CONTACT 8 TELEPHONE # V�u(.G PAp�LLQ 5)D- 933 • 0579 <br /> F FACILITY NAME F.�J'�n S"T�TNt� PHONE # �Icl- 1-177 , 17<) <br /> A <br /> C ADDRESS 301 w . A ,A \-\OL. D(-1Jt <br /> I <br /> L CROSS STREET w& SI D-L QfE`>p p f �,.i11n-Q <br /> I PHONE # <br /> T OWNER/OPERATOR <br /> Y SN'sli 0)(- <br /> C <br /> )(C CONTRACTOR NAME - PHONE # SiU r'GS <br /> - N <br /> 0 <br /> N CONTRACTOR ADDRESS) 45(, Oh-T Loo C-Co.K,C CA LIC # 2.g37D0 CLA S - Z L <br /> T - 'y <br /> R HAZARDOUS WASTE CERTIFIED YESC NO IJ t.:L'-3Z3Z'-JZ <br /> A PERMIT # <br /> C FIRE DISTRICT e Lh O� C_V <br /> T <br /> 0 BOARD OF EQUALIZATION # H N Q 3 Ce "- O k <br /> R <br /> TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- rosTANK ID # 1 S a0U T ec t PR.-n WH MnLSDFD cl -_DATECj (0_ <br /> G 9L <br /> A 39- 5 <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 <br /> P <br /> L APPROVED >( APPROVED WITH CONDITION(S) DISAPPROVED <br /> CC <br /> A (SEE ATTR HNENT WITH CONDITIONS) DATE <br /> N R <br /> PLAN EVIEWERS NAME <br /> PLAN RE <br /> APPLICANT MUST PERFORM ALL 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: "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 /> 1. CONTRACTOR'S <br /> HIT �TCILCSIGNATURE THE <br /> SWING: <br /> SUBJECT <br /> TOWORKER'SCOMPENSATION <br /> OOFCALIFORNIA. <br /> ONS SUBJECTTOWORKER' <br /> ET[ THE PENCE OF WORK FONWNICNTHPERMITISSSUEDSNAEMPLOYPERS <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> ��,�, / �n�_ TITLE Gt�'FG/ici/ DATE <br /> APPLICANT'S SIGNATURE: �/!1/' / l cam- <br /> Indicate the responsible party to be billed for additional. PHS-EHD staff time expended beyond the 8 hour minimum instaLLation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and,date below. <br /> Name ° ENG/klFf.Q/A.G JX/C . <br /> Mailing Address CzLih, L. (cgor lz:'xi 3r3 L"-AL-N��rt C.�>;�r -l.A `�N5S L, <br /> Day Phone Number 5 Cl33'o�7a' <br /> Signature <br /> EH 23 008 (Rev 12/1 5, UST Reg's y 1994 _ <br />