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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. <br />EPA SITE # CA 7 1 93S i 7 1 PROJECT CONTACT 8 TELEPHONE # _ <br />F FACILITY NAME CPHONE #201-_3 7 <br />A <br />C <br />I ADDRESS 6q2j RpGpnC4e <br />L CROSS STREET =- <br />I <br />TOPE�TOR PHONEYC O 1 pes --01? <br />OC CONTRACTOR NAME S PHONE # = <br />C z • 1 - �J.�-� <br />N CONTRACTOR ADDRESS z� Q t CA LIC # 10 CLASSG6 j 0 <br />T I <br />R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.#Rr Q 7� <br />A <br />CFIRE DISTRICT PERMIT # <br />T ac�,�IA I <br />0 BOARD OF EQUALIZATION # <br />R <br />IIIIIIIIIIIIIIIIIIIIIIIIIIiIIi <br />TANK ID # TANK SIZ CHQUCALS TO BE STORED PROPOSED INSTALLATION <br />39- <br />T 39- /A . O GO i+ DATE <br />A 39- 00 P7 Oa3 <br />N 39- <br />K 39- <br />39- <br />39- <br />IIII <br />P <br />L APPROVED ✓ APPROVED WITH CONDITIONS) DISAPPROVED <br />A —( E ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME )L :: , _r >; _ DATE Y <br />Iillliltllliillllllllilll IIIII II I I I I I II I 111111 I II IIIIIIIIII <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, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PE ORMANCE TH ( FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER -S <br />COMPENSATION LAWS OF CA F A." <br />APPLICANT'S SIGNATURE: _ TITLES DATE <br />inaicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name { �Tpp� �[ t CryT-�yi� t.�li1 ( lA1? C�� <br />Mailing Address <br />Day Phone N r — <br />Signature Date <br />CL-�c � )v'rEH 23 008 (Rev 1/7/92) WP / Y� <br />bi Sc.L•-off � � 3%-� J�^ o�vc+-^ -��`-' ' / � <br />W/ 7r -k .�4' <br />