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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 RHS-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 # (: � �1�51 `I ��� PROJECT CONTACT 8 TELEPHONE # `�� P�aC>�LL A (�[U e" 3 15V <br /> F FACILITY NAME C" PHONE #2k-c7_ . <br /> A <br /> C ADDRESS �-C fC�� i k1'11a �" t > 0 <br /> l <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> C CONTRACTOR NAME • , >L �N C. , sb.-,2 4L +S>7��' PHONE # <br /> N CONTRACTOR ADDRESS iia CA LIC # CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES _ NO WORK.COMP,# <br /> A <br /> C FIRE DISTRICT C-kIVN PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK <br /> IIIIIIIIIITANK iliIII111I11i1 <br /> ID # TANK SITE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- t 1 c fao Cy,,4scLuNT (LYx �I saA 41n1-1aDis'J [•:G . DATE /0 <br /> T 39- C c •, ^amu Al c �i1 <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> III <br /> P <br /> L APPROVEDA <br /> APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ATTACHMENT WITH CONDITIONS) PATE Z <br /> N PLAN REVIEWERS NAME <br /> 1111111111111111111111111111111111111111111111!1111 I llllllllllll 1Jill <br /> 11111llllllllll <br /> Jill <br /> llllillll II Illllllllllllllll llll <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: "1 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." /� <br /> APPLICANT'S SIGNATURE: � r`1 a TITLE �il-V' k V;WWi-kM- DATE <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_ ��/� <br /> MaiLing Address lai4d/e cogxy- Soelf 903 WAOT t- <br /> Day Phone Number S)0 - / yi J� <br /> Signature Date <br /> EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) <br />