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-'rl <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br />THE APPLICATION FOR INSTALLATION Or w4OCRGROUND STORAGE TANXS IS ONLY VAt ID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN <br />ISSUED. A PERMIT MAY HE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THF. CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER, <br />PROJECT CONTACT: � -- CONTACT PHONE # <br />FACILITY NAME:jP <br />FACILITY PHONE# <br />FFACiLJTY ADDRESS: <br />.0 cam/ 4D, - <br />CONTRACTOR NAME: I ...... <br />CONTRACTOR ADDRESS: � �—� ` �'--� -7 S <br />CA LICENSE # <br />_ _ 7 3 <br />HAZARDOUS WASTE CERTIFICATE: WORKERS COMP # <br />�{ YES NO 9eq''.�©�Je�o7©l� <br />FIRE DISTRICT: PERMIT # <br />BOARD OF EQUALIZATION <br />Y — CIkJ��C���—� _ <br />T <br />TE <br />I <br />APPROVED APPROVED IMTH CONDITIONS ❑ DISAPPROVED <br />e (see attachments) <br />PLAN REVIEWER'S NAME <br />_ DATE <br />APPLICANT MUST PERFORM LL WORK —INA ORDAN WITH SAN JOAQUIN COLJNTY ORDINANCES, STATE LAWS, <br />RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br />SIGNATURE CERTIFIES THE FOLLOWING° 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.- CON FRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br />CERTIFIES THE FOLLOWING -1 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 �tJ�'� <br />�-�'�.--- Date � <br />Indicate the responsible party to be billed fer additional 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 <br />Signab <br />Revised 7/26/2016 <br />Date <br />J]aytimB Phone LfOSC� f'n 7 i s�`q <br />