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11/26/01 12:08 FAX 209 942 1'"14 Siegfried Eng 0 002 <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 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-END 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. <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # <br /> co <br /> F FACILITY NAME <br /> PHONE # G� <br /> a <br /> C ADDRESS - M frnkp � w (� <br /> t <br /> L CROSS STREET �Mbv ) Inf 5it7►J �J <br /> I PHONE # <br /> T OWNER/OPERATOR ,} _ %-I-L/I 1-7 <br /> Y T -DVA JI'DUI `Y (SSS 1-� <br /> C CONTRACTOR NAME f PHONE # zoo <br /> _ <br /> .,f�t7T n�S'('��G T1 O r.f <br /> N CONTRACTOR ADDRESS W3�� ' L)C, ;L-� 2 CA LIC # Z3?9 u o CLASS <br /> T WORK.COMP.# <br /> R HAZARDOUS WASTE CERTIFIED YES _ NO <br /> — <br /> A PERMIT # <br /> C FIRE DISTRICT <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK ID # TANK SIZE CHEMi4ALS TO BE STORED PROPOSED INSTALLATION <br /> 39t7,�D /� Ut� 11YL�CL � DATE 2DD? <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111111 <br /> 7 <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE FOR WHICH THIS PERMIT IS ISSUED, i SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFOR IA." <br /> APPLICANT'S SIGNATURE: TITLE _ 0110 DATE <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the B hour minimum installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name `� n 1 115 5 <br /> Mailing Address 1-4 LW&/Day Phone Phone Number — —'✓0 I <br /> D" Date <br /> Signature <br /> EH 23 008 (Rev 12/13/95, UST Reg's May 5, 19 4) <br /> 4 <br /> E <br />