Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPART ;;._. <br />MENT <br />SAN JOAQUIN COUNTY <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUNn STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN <br />ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONETIME, ONE YEAR EXTENSION MAY BE GRANTFn R4 Fun Y ionki <br />JItiNAI URE CERTIFIES THE FOLLOWING' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK OREWH CH THIS <br />PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br />CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br />ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' <br />Applicant's Signature <br />Date _LQ <br />Indicate the responsible party to be billed for additional END 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 -J- r I <br />Date <br />Mailing Address q f <br />Signature— 9 <br />,.� <br />Dayfime Phone <br />Revised 7/26/2016 <br />