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Jan 31 OS 10 : 30a _Christina Gill 707-360- 1307 p. 3 <br /> JAN 31 2005 8: 18AM OHL DESIGN GROUP 0 <br /> 7 765 9908 p. 2 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STOfp10E TANKS IS ONLY VALID FDR THE CALENDAR YEAR IN WHICH R WAS BEEN <br /> ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TD END REOUESTING THIS EXTENSION THIRTY <br /> DAYS PRIOR TO THE ENO OF THE CALENDAR YEAR A ONE TME ONE YEAR EXTENSION NAY BE GRAWED BY ENO UPON RECEIPT OF THIS <br /> LETTER <br /> PROJECT CONTACT:J m CONTACT PHONE# n _76 5- <br /> FACILITY NAME:A*�,z" ar. FACILITY PRONE# /r�vr- %p04wFACILITY ADDRESS: Av. CROSS STREET: <br /> OWNERIOPERATOR: PHONE: <br /> l`>TA�iTCa,oE �E"idT•E0,- v�u.c 707- 3Z10- i3H[o <br /> CONTRACTOR NAME: c co ysz Lr PHONE: _ 6 z _ 'q <br /> CONTRACTOR ADDRESS: `X410 YI'"'A HL"-� UD CA LICENSE# 77f 0ja <br /> HAZARDOUS WASTE CERTIFICATE:QffS NO WORKERS COME 4 <br /> FIRE DISTRICT: rt,Q y7�,d/L.A pyWv-r PERMIT# <br /> BOARD OF EQUALIZATION# <br /> ANK ID# TANK SIZE CHEMICAL STORED PROPOS INSTALL DATE <br /> �j3�(OS I S 0 0 5 <br /> 1 �r r.:r a.: s Xe B <br /> os 3 0 , doA�. <br /> S 1-( <br /> 0 APPROVED 'APPROVED WITH CONDITIONS O DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAM r DATE 5-12610S <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMtNT,OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES TEE FOLLOWIYG"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> PERMIT IS ISSUED„I SHALL NOT EMP---OY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECr TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORN.-A"CONTRACTOR'S HIRING OR SUHCONTRACITNO SIGNATURE CERTIFIES THE <br /> FOLLOWING"1 CERTIFY THAT IN THE PERF OF THE WORK FOR WHICH Tli IS PERMIT IS ISSUED,I SHALL <br /> EMPLOY PERSONS SUBJECT TO WD 'S MPEN AT NLAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURk <br /> TITLE J DATE <br /> Indicate the responsible party to be billed for additional EHD staff tithe expended beyond the 8-hour <br /> minimum installation payment.The party must acknowledge this responsibility for the additional billing <br /> by signature and date below. <br /> Name_F, � T LAaC- L&Vw4t- jaL.c_L_.I, I -.c Date <br /> .140ing Address f qvo nL oa rro_v A,lW c..P el - 54ry74 Aaf?41 ed • 9540/ <br /> Signatlne Daytime Phone 7o7-3zrr•i3610 <br /> C. REQUIRED SUBMrITALS <br /> 3 - <br />