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E VIP. NMIENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICA1I0N FOR INSTA ELATION OF UNDERGROUND.STORAGE TANKS IS ONLY VALID FCR THE CALENDAR YEAR IN VVHICH 1-1 HAS BEEN <br /> ISSUED. A PERMIT MAY BE RY.s ENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR, A ONE TIME,On'E YEAR F_XTENSIO-N MAY EE GRANTED SY EHD UPCN RECEIPT OF THIS LET TER. <br /> PROJECT CONTACT: CONTACT PHONE <br /> FACILITY NAME: FACILITY PHONE= € <br /> FAGILI . ADDRESS: CROSS STREET: <br /> OWNERIOPERATOR: ' - PHONE. <br /> CONTRACTOR NAME: � ��,")�[{ � PHONE_ <br /> `dice., <br /> CONTRACTOR ADDRESS: J CA LICENSE M <br /> � I <br /> ZARDOUS WAST CERTIFICATE: WORKERS COMP K <br /> - x `7 Tr <br /> YES_._ �. NO I ��..w,G,,,�-�� �� 1�•-• .��- <br /> FIRES DISTRICT: r PERP:iT <br /> BOARD OF EQUALIZATION� <br /> Q° <br /> TANK ID# I ANK SIZE { CHEMICAL STORED PROPOSED INSTALL DATE <br /> FIAPPROVED - `<APPR,OVEDWITH CON DITIONS El DISAPPROVED <br /> sca attachMen <br /> e atta m <br /> - <br /> E <br /> PLAN REViE1NER,S NAME �! 0AI E <br /> APPLICANT MUST FERF' IRM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE L�VIAS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> vVORKFP.'S COMPENSATION LAIMS OF CAL;FORMA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br /> CERTIFIES THE FOL-_OWING "I CERTIFY THAT IN THE PERFORMANCE OF THE WOPsK FOR WHICH THIS PERIAT IS <br /> ISSUED,I SHALL EMPLOY PEF ONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA," <br /> ApplicansSignature <br /> Title I co nc; , =c r Date 10-1-5 <br /> i indicate the responsible party to be billed for additional EHD staff time expended beyond the 6-hour ;Minimum instaiiation <br /> payment_The party must ckmcwledge this responsibility for the additional billing by signature:and date below <br /> i <br /> Narne _' or.,rr rrro/\ _ Date <br /> M9iIingAtiddkr ,s - __ +�. ��t\ c Jr$t3�' i.a441 6"We K4GXa'+ue <br /> Signatura�` __........__ Daytime Phos_ S- &SQ-s0:! <br /> 1� <br /> Revised 07/24/113 <br />!h <br /> i <br />