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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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 PHS -END REQUESTING THIS EXTENSION THIRTY DAYS 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. DO NOT WRITE IN ANY SHADED AREAS. Indicate the responsible party to be billed for additional PHS-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. Mailing Day Phone Number_ ( 'f 16 )— Si EH 23 008 (Rev 7/7/92) WP 3 E # TD8 0O �6 7. PROJECT CONTACT 8 TELEPHONE # Steuen 11 FAY NAME ( Q ( _/ EADDRESS PHONE # 'fld C 'fI c L I CROSS STREET w -f" JlILVe T OWNER/OPERATOR ?ao-Vi( &H PHONE # Y I o Fra 93712 i C 0 CONTRACTOR NAME n PHONE # $'lO N T CONTRACTOR ADDRESS SD OftCanyon CA LIC # pp CLASS 1 R A HAZARDOUS WASTE CERTIFIED YES ) NO WORK.CCMP.# C FIRE DISTRICTL-1- 1 PERMIT #e T 1 l l 0 R BOARD OF EQUALIZATION 7 IIIIII1111TANK 111111111111111 TANK ID # SIZE CHEM PROPOSEDDATEINSTALLATION I1"L TO,B 39- 31 00 (TORED tj T 39- A 39- N 39- K 39- 39- 39- P IIII L Xjr APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A ( EE T ACrMENT WITHCONDITIONS) N PLAN REVIEWERS NAME III IIIIiiiiiiiiiiiii I DATE 111111 I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: / r TITLE rL,4 ,z4,&t4=L-X DATE IO Indicate the responsible party to be billed for additional PHS-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. Mailing Day Phone Number_ ( 'f 16 )— Si EH 23 008 (Rev 7/7/92) WP 3