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io <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT 2: <br /> THE <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 PNS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE # <br /> F FACILITY NAMEi=Z PHONE # q-JZ, (� � <br /> CJD �-I �5 TU —rJ-�G�. <br /> A <br /> C ADDRESS �� <br /> 1 <br /> L CROSS STREET C�(Z�Y� yvr5 jD QL\f <br /> I PHONE # <br /> T OWNER/OPERATOR <br /> Y T b�A �I��l)y SS <br /> C CONTRACTOR NAME n PHONE # _ <._��_ 6� /✓v <br /> D .�GNDI rJ.S�—11CTIOr� <br /> N CONTRACTOR ADDRESS CA LIC <br /> # CLASS <br /> T WORK.COMP.# <br /> R HAZARDOUS WASTE CERTIFIED YES NO <br /> A PERMIT # <br /> C FIRE DISTRICT <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK SIZE CHEMI4ALS TO BE STORED PROPOSED INSTALLATION <br /> TANK ID # DATES <br /> 39- r�D Sct�l'1' rPC`�}11✓ a P?'eYYIIUr� UYl-�GiDI.t:C.i- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> III <br /> P APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> L <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 1N <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 THEFOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFOR IA.11 <br /> APPLICANT'S SIGNATURE: TITLE OLO(V DATE <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 --5n <br /> Mai I ing Address_ $Q1-4 (,W1,1 brAVO - r JIUCk ro�-- <br /> Day Phone Number C i� <br /> —Ozf4�z <br /> '�' <br /> Signature Date <br /> EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) <br /> 4 <br />