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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE PPLICATION FOR INSTA:LATTON OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN <br /> ISsul O. A PERMIT MAY eR QXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIG TO TME ENC OF THE CALENDAR YEAR A ONE TIME,ONa YEAR EXTENSION MAY ae GRANTED BY EHD VPON RECEIPT OF THIS LETTNR. <br /> PRI JECT CONTACT: CONTACT PHONE# <br /> PAI ILTTY NAME: FACILITY PRONE# <br /> I-aq-LAS-6-(Lj L <br /> FA f,M ADDRE : CROSS STREET: <br /> E"PERATOR: PHbNE: <br /> S6 <br /> CO "TRACTOR NAME: PHONE! <br /> 4 L. <br /> CONTRACTOR ADDRESS: CA LICCLNSE# <br /> 0 7msD <br /> HA7ARDOl1SWASTE CERTIFICATE: WO COMP <br /> VES NO <br /> 1`111 DISTRICT: PERMIT It <br /> RO RD OF EQUAL17.ATION N <br /> TANK ID# TANK SIZE CHEMICAL STORED ROPOSED INSTALL DATE, <br /> Miryl, A& <br /> C APPROVED ❑APPROVED WI DTTTONS ❑DISAPPROVED <br /> (see attachments) <br /> Pl, N REVIEWER'S NAME DATE- <br /> APF ICANT MUST PERFORM A�♦F CCOkOANCE WITH S4N JOAOWN CAUNTY ORDINANCES.STATE LAWS, RULES AND <br /> SAl, .IOAQUIN CCUNTY ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSW AGENT'S SIGNATURE CERTIFIES THE <br /> FO OWING'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMR IS ISSUED.,I SHALL NOT EMPLOY <br /> AN PERSON IN SUCH AAS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> CO TRACTOR'S HIRING 0 SUB TING SIGNATURE CERTIFIES THE FOL,LOWINO°I CERRFY THAT IN THE PERFORMANCE <br /> OF E Vu®RK FOR WHICU1,11% R IS ISSItF,p�RNALL EMPLOY PERSONS SU6JECT TO WORKER'S QOMPEN'SATION LAWS <br /> OF AUFORNLA," <br /> A licant's Signatu _ <br /> Ti i c frV4 —,, e— Date <br /> Ind ate the responsible party to he billed for additlonel EHD Staff Ilene expedded beyond the S•hour minimum Installation <br /> pay rent-The party must acknowledge this responsibility for the ncidiNonal billing by Signature and date below. <br /> N.9 TIC Date <br /> M iling Ad R 7a� � � J � t S <br /> Sit natute 7 Daytime Phone <br /> & f z?. .706Z <br /> Revived 9/3/07 3 <br /> un In Stld 50:90 !T7Z;d9 u <br />