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04/01/02 14:39 FAX 209 942 0214 Siegfried Eng f]002 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> ANPERMITIMAYIBE EXTENDED INTO ITHE NEXT O£ALE DAR YEAR AIF AGE ALETTER NKS IS 015LSENT LTO PHS-EHD REQUESTING ID FOR THE CALENDAR ETHIS AR NEXTENSION THIRTY WHICH IT HAS DAYS <br /> SUED. <br /> DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHO UPON RECEIPT OF THIS LETTER. <br /> 00 NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE # <br /> F FACILITY NAME d <br /> A �,t <br /> C ADDRESS / ft-M <br /> L CROSS STREET &'TCCA,Y0 o>-1b rJ 6LUa <br /> I PHONE # <br /> T OWNER/OPERATOR <br /> Y -298 IbOD LASS <br /> PHONE # zocY _ 4-7 <br /> C CONTRACTOR NAME .�� <br /> • qJp f�15 ia lSCT1Dt� <br /> N CONTRACTOR ADDRESS aft f L) L–� 0a CA LIC # Z 3 tv Q CLASS <br /> T WORK_ <br /> R HAZARDOUS WASTE CERTIFIED YES - NO COMP.# <br /> A PERMIT # <br /> C FIRE DISTRICT <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> IIIIIiIII1I{IIIIIIII111IIIIIII TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39• <br /> TANK ID p DATE 'L1�D9 <br /> aD, DSD 'f <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 111 11111111111ITrwiffn Hill IIIIIIMII HIM III <br /> P <br /> L APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) DATE <br /> N PLAN REVIEWERS NAME 1 1 II 11111I II 111111 11 11 <br /> IIIIIlillllllllll111 I I 11 <br /> APPLICANT MAST PERFORM ALL WORK IN ACCORDANCE U17H SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 111 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 /> "1 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 I ." <br /> APPLICANT'S SIGNATURE: LOY TITLE 0A-1, GATE q ZlO{�f <br /> Indicate the responsible party to be billed for additional PHS-EMD staff time expended beyond the B hour minimus installation <br /> payment_ The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name D S <br /> MA!I ing Addresa� 101-4 &&W <br /> Day Phone Number <br /> Signature Date 12u*,0 <br /> EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) <br /> 4 <br />