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1 1 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR THE 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 YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. t <br /> EPA SITE # Z 3 S PROJECT CONTACT & TELEPHONE #—7 <br /> c1 1 I D=j <br /> F FACILITY NAME * Z,l g(5> PHONE <br /> C # <br /> A <br /> C ADDRESS Z Z (JD 1 r p t a- <br /> I <br /> L CROSS STREETj <br /> I PHONE # <br /> T OWNER/OPERATOR v <br /> ONE 2O 3' `J <br /> C CONTRACTOR NAMEc \ \ <br /> 0 CA LIC # =-� (' <br /> LASS <br /> N CONTRACTOR ADDRESS O ��� — O <br /> T WORK.COMP.# <br /> R HAZARDOUS WASTE CERTIFIED YES _ <br /> NO— <br /> A _ PERMIT # <br /> C FIRE DISTRICT L F -' <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> 111111111111111111111111111111 TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- TANK ID # ?(� 0 0 DATE <br /> T 39- r l�n(1 <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39IIIIIIIIIITHIIIIIIII <br /> - <br /> II11 <br /> PED WITH CONDITION(S) DISAPPROVED <br /> L APPR APPROVED <br /> A .�-I�/ (SEE ATTACHMENT WITH CONDITIONS) DATE <br /> N PLAN REVIEWERS NAME I I I I I I <br /> 11111111111111111111 <br /> I <br /> APPLICANT MAST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS 0 <br /> CES. OWNER O <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I 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 at CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA."" <br /> APPLICANT'S SIGNATURE: v 4 I TITLE�1��\t C �`�1 G� - DATE <br /> for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment- <br /> indicate the responsible party to be billed <br /> The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name <br /> �F� _� 50 <br /> Mailing Address <br /> Day Phone Number �(-4 `D S <br /> Date <br /> Signature � (-'y <br /> EH 23 008 (Rev 1/7/92) WP <br /> 3 <br />