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t <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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 YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER, <br /> DO NOT WRITE IN ANY SHADED AREAS{. <br /> EPA SITE # Lftk r PROJECT CONTACT & TELEPHONE # *L 461 <br /> F FACILITY NAME M PHONE #I <br /> A - <br /> C ADDRESS �41 11 <br /> �! <br /> 1 C1 <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR, PHO # <br /> Y — <br /> � — <br /> C CONTRACTOR NAME y <br /> PHO # <br /> 0 <br /> N CONTRACTOR ADDRESS A LIC # GG CLASS <br /> T <br /> R HAZARDOUS HASTE CERTIFIED YE NO WCRK.COMP.# �U <br /> A Ov <br /> (1469L 7344 <br /> C FIRE DISTRICT PERMIT # <br /> T - <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> rllirlll l l l llll111111l1111111r <br /> TANK ID # TANK SIZE CHEM CALS TO BE STORED PR .0$ED INSTALLATION <br /> 39- 7r ' DATE <br /> T 39 <br /> A 39- fl <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> rill <br /> P <br /> L APPROVED VWITH CONDITION(S) DISAPPROVED <br /> A SEjL.TTZHZNT WITH COWD1T10WS)N PLAN REVIEWERS NAMEDATE <br /> IiirIIlllllllllllllli 11rr1 Illi I I ILII 1II11111 II1111I1111111111111111I111I1111111111111II[111lI 1lIIIi !11lIIIIII <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 HICH THIS PERMIT IS ISS , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATIO !LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT 1N THE PERFORE <br /> THE WORK FOR W I H THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORN <br /> APPLICANT'S SIGNATURE: TITLE I/ II .C/ DATE <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br /> The party must <br /> �^a�cknowI dgfe this responsibility for the addit"onal billing tsy� signature and date below. <br /> Name 6 4 (�V t � Q j� <br /> w <br /> Mailing Address q br41 <br /> Day Phone Number / <br /> Signature <br /> Date <br /> EH 23 008 (Rev 1/7/92) WP <br /> 3 <br />