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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC &C <br /> ENVIRONMENTAL HEALTH DIVISION �• <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION(#E5M9I n <br /> ENV1p 199 <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CAL ARQE�AI��lIAI�f(I CH IT HAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-END REO f��rry�/"j�L(S'EY(fLW�IQt�,�L�74IRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EflO UO(Se PYLOFl All LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> �CEv <br /> EPA SITE #C981N59�OI3I PROJECT CONTACT 8 TELEPHONE Lu(-1s e*1LLVA $)O• t] • os7g <br /> F FACILITY NAME .ELL EV'.J'Lfi � PHONE # 97 _ 1743 <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET W& SID-L <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y I SNiu- 01(, SIo -475 - W �1 ' <br /> C CONTRACTOR NAME N PHONE # S/d a- <br /> 0 <br /> N CONTRACTOR ADDRESS.yI 45CA LIC # 2c/3700 CLA S -.0, RAZ L <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES )L NO_ WORK.COMP.#us,,34 3Z3Z--ate <br /> A <br /> C FIRE DISTRICT Glk b� LtiTC7 aj PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # N N Q 3 fe — O 0 1 <br /> R <br /> TANK 1D # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- "DSC 1 5 00c) r, %C� tw5 pern"Jkr M LKOFL7 _DATE C to_ <br /> T 39- 15, 000 r ecoL�.» ut�LSOY'9 C�i6LLLpd G 9 L <br /> A 39• S'-159 — <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> L APPROVED >( APPROVED WITH CONDITION(S) DISAPPROVED <br /> A - SEE ATTA HMENT WITH CONDITIONS) CC <br /> N PLAN REVIEWERS NAME G DATE �(J <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: "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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA."APPLICANT'S SIGNATURE: 'f��i 2�✓ /�/�-��— _ TITLE A-ZlAri'?//yL� CC!°W74-! DATE <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 /> NameEN6/N�hf�/NG rflC <br /> Mailing Address H5 CZUQIL. (OL( S-it 3b3 WQL'NL�Z` �4�r -La HS�J <br /> Day Phone Number 6 )!D- s 3.0 7d' nn <br /> Signature Date <br /> EH 23 008 (Rev 12/7 UST Reg'sy 1994 <br /> 4 <br />