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� l <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 1S 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. <br /> PROJECT CONTACT & TELEPHONE # <br /> EPA SITE # <br /> F FACILITY NAME �CL �� � PHONE <br /> A <br /> C ADDRESS <br /> L CROSS STREET <br /> (.fk(LD(�`l� In1�SiD� TSi.0 P <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y WC J�60D 14 <br /> C CONTRACTOR NAME l�C� PNONE # ZOq ,1-7_ /Q <br /> O CA LIC CLASS <br /> `/ <br /> N CONTRACTOR ADDRESS 3 �Q 1 b J G�i _L-� 2 # Z?3 U O <br /> T J <br /> R HAZARDOUS WASTE CERTIFIED YES - NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT >Y <br /> T <br /> O BOARD OF EQUALIZATION # <br /> R <br /> TANK ID # TANK SIZE CHEM14AL5 TO BE STORED PROPOSED INSTALLATION <br /> 39- � t Itgglia✓ 4 preX111UY►` IjYL�(�1Dttd. DATE 1 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9- <br /> 39-39-P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> IIIIIIIIIIIIIIIIIIIf III I IIIIIIIIIIII 1111111 <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 1N 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFOR IA." <br /> APPLICANT'S SIGNATURE: TITLE Oznewl DATE LI'Z10-0 <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name 1�by1D `l as S <br /> Mai Iing Arkiress 101.4 L.Wf-1 �(A-C1 -------_ �bt,IlJfD}— <br /> Day Phone Number -C � rl <br /> 4 el <br /> Signature <br /> Date <br /> EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) <br /> 4 <br />