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i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FORTHE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. ��//1�'� <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # 76 7 -766 K <br /> —60 <br /> F FACILITY NAME 4jq WAY 6-TC--ipe # 2Z, � PHONE # qZr- —?1J <br /> A _ <br /> C ADDRESS"` <br /> 1 1 <br /> L CROSS STREET <br /> T OWNER/OPERATOR PHONE <br /> � # <br /> Y `V 6125) x- <br /> C CONTRACTOR NAME PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC # CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# <br /> A �� J <br /> C FIRE DISTRICT r \ "���- l ti � PERMIT it <br /> i T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> IIIIIll11111111111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- DATE <br /> T 39- �� � A&A ' H <br /> A 39 Z�" a fL ,`� �`(f�t /7C T l�1�� �C�M tlN MAiZ H ?L2--? <br /> N 39- <br /> K 39-- <br /> 39- <br /> 39- <br /> P <br /> 939- <br /> 39- <br /> P <br /> L APPROVED _ APPROVED WITH COND1T10N(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> lillllilllllilllllilllllll tl II III 11 I II II 1111111 I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: 1 3 �! "'^� TITLE i �t l/<<� DATE lc Ykp ki <br /> Indicate the responsible party to be billed for additional PHS•EHD staff time expended beyond the 8 hour minimum installation <br /> payment. Thepartymust acknowledge <br /> � this <br /> 1r�esponssiib�iiLiitty,for the additional <br /> bitting by�signature <br /> �-and date below. <br /> Name a fT L� 1 c7�C�I�I --(CZ>�?�/ I'�C I AA.�� WALIFE- <br /> - <br /> Mailing Address 113? I `C —1 C ► / �DWELL_ 3CX. IF_L__ b lR�U WSA <br /> LA <br /> Day Phone Number b27 ) <br /> Signature Date <br /> EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) <br /> 4 <br />