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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN COUNTY APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT THE NKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. AI PERMIT MAY BE EXTENDCATION FOR ED ED INTO THE NEXT CALENDAR YEAR ON OF UNDERGROUND STORAGE AIF A LETTERS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. PROJECT CONTACT: CONTACT PHONE# FACILITY NAME: FACILITY PHONE# FACILITY ADDRESS: CROSS STREET: OWNER/OPERATOR: PHONE: CONTRACTOR NAME: PHONE: CONTRACTOR ADDRESS: CA LICENSE# HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# YES NO FIRE DISTRICT: PERMIT# BOARD OF EQUALIZATION# TANKED# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE ❑APPROVED D APPROVED WITH CONDITIONS ❑DISAPPROVED (see attachments) PLAN REVIEWER'S NAME DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED., I 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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." Applicant's Signature Title Date Indicate the responsible party to be billed for additional 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. Name Date Mailing Address Signature Daytime Phone Revised 061108 3