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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-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PNS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # Cqr Q 8o G 2637 <br /> 4PROJECT CONTACT 8 TELEPHONE #xlsHwortb /` _97.2- <br /> F FACILITY NAME PHONE # <br /> A <br /> ADDRESS <br /> I o ewoS !'� \ <br /> c� c-� <br /> L CROSS STREET A14!rsr- LXX ff- <br /> 1 <br /> T OWNER/OPER OR PHONE # <br /> Y �.4 �i.ci� /G • 971 .1 <br /> C CONTRACTOR NAME 10L0A9SQQ <br /> SV A1eWe # <br /> qxg <br /> N CONTRACTOR ADDRESS YQ LA LIC # PHONE CLASS <br /> T .0 [ 1) �7D <br /> R <br /> HAZARDOUS WASTE CERTIFIED YES NO_ WORK.COMP.# /04 39 ZV6 <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- DATE <br /> 1 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P IIII � <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 CALIFORNIIAAA.."/_`(�///�� �/J <br /> APPLICANT'S SIGNATURE: /r/=C"�"'�7 `� ) TITLE //►�SJ� DATE <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 mat this responsi-bi/ly for the d/ Nditional billing by signature and date below. <br /> n <br /> � sQN\ <br /> Mailing Address / 4o &OX7 /S ,OQ <br /> Day Phone Number . - 7� '3 /a <br /> Signature f - L- d �i.�.o.n.� Date <br /> EH 23 008 ( ev 12/13/95, UST Re ' ay 5, 1994) <br /> 4 <br />