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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 PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE # X4jC•&4p.g2 wNL'rOa( <br /> F FACILITY NAME � C 0 #to C, PHONE # 20c1 --3 6 r( — OcIS" <br /> A <br /> C ADDRESS VI C.-I—o✓ D <br /> 1 <br /> L CROSS STREET �-k W cr ri <br /> I PHONE # <br /> T OWNER/OPERATOR <br /> Y SO 14- [-4 SI .-( <br /> C CONTRACTOR NAME W A LTat-( E pC (� 1 eC Ii.Il.i +-LC �Ac L PHONE # W 6 _ •3 4 3_ ( 1 S L <br /> 0 W_ SAi+W C'A CA L I C # CLASS A I tAA� <br /> N CONTRACTOR ADDRESS P, C), Q O X /07-5- s-G q <br /> T WORK.COMP.# <br /> R HAZARDOUS WASTE-CERTIFIED YES NO_ 13 - rY2 <br /> A PERMIT # <br /> C FIRE DISTRICT <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> 1111'I11'I"'�'I11'1'I1'I1f1� TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> TANK ID # <br /> Z <br /> 39- 03, 12 O u o l FIS HA �✓�2- DATE 02— <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- fTfff11Tf111TI Iff[TT <br /> 1111 <br /> P <br /> L AP VED APPROVED WITH CONDITION(S) DISAPPROVED p <br /> A � . EE ATTACHMENT WITH CONDITIONS) DATE 0 Z <br /> N PLAN REVIEWERS NAME <br /> 111111111111111111111TI1 1111 <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: "T 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 CALIFORNIA." •'7� /b 0 <br /> APPLICANT'S SIGNATURE:CALIFORNIA. <br /> ' TITLE f��li/S DATE I <br /> iM 1 CIA A- WA LT <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name 'z' J it- �'i/�C C to t� <br /> Mailing Address g ff O I/ I C"-Oti g b C-A 'I S- 2 '(0 — <br /> Day Phone Number <br /> Date <br /> Signature <br /> EH 23 008 (Rev 12/13/95, US Reg's May 5, 19943 <br /> 4 <br />