Laserfiche WebLink
J18 <br />ENVIRONMENTAL HEALTH DEPARTMENT z <br />SAN JOAQUIN COUNTY <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 rr 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 ONE TIME, ONE YEAR EXTENSION MAY SE GRANTED BY EHD UPON RECEIPT OF THIS LETTER, <br />PROJECT CONTACT: CONTACT PHONr; # <br />FACILITY NAME: FACILITY FHC31VFi3 <br />NAME: <br />CA LICENSE # <br />?e F79 3� <br />YES NO-�Oi�s"o?0/� <br />�RICT: PERMIT <br />F EQt;I iKlITION # <br />4NK ID # TANK SIZE CHEMICAL STORED <br />PROPOSED INSTALL DA' <br />Ca �? J ?�! <br />COD ! r <br />G Pr <br />❑APPROVED AAPPROVED WITH CONDITIONS <br />DISAPPROVED <br />(see attachments) <br />PLAN REVIEWER'S NAME �i c� c <br />DATE I 5 o�O <br />APPLICANT MUST PERFORM LL WORK IN ACCORDAN WITH SAN JOAQUiN COUNTY ORDINANCES, STATE LAWS, <br />RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGEN i S <br />SIGNATURE CERTIFIES THE FOU OWING' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 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 />Title ,!' i� Date 63 - d2 <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 ourh minimum installation <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name IL/_,r 0/-., )nd,—)�, c_Y__ <br />Date <br />Mailing Address _l� —�-- S <br />Signature <br />Daytime Phone <br />Revised 7/26/2016 <br />