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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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. A PERMIT MAY <br /> BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR <br /> YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> CONTACT PHONE# <br /> PROJECT CONTACT: L_0 r I �i��S H O U Ye,— C( l Cp BSS I O 9 O <br /> FACILITY NAME: A RIC FACILITY PHONE#O (p 3 3 <br /> rn A n�Tt C R CROSS STREET: <br /> FACILITY ADDRESS: I k O O <br /> OWNER/OPERATOR ()p PHONE:A �C C 503 23�� 3 O <br /> CONTRACTOR NAME: T Ia t T c= PHONE: <br /> t <br /> CONTRACTOR ADDRESS: CA LICENSE# CLASS:A Lr3 <br /> 2$ Lt.�`It.IMG '�2. R - CO2O0 VA CPt dSv9 $ <br /> HAZARDOUS WASTE CERTIFICATE: nYES 7NO WORKERS COMP # <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION # <br /> TANK ID# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE <br /> E]APPROVED PROVED WITH CONDITION []DISAPPROVED <br /> I /� n/(►see attachment with conditions) 1 <br /> PLAN REVIEWER7NAMES /�X�1/ V DATE <br /> a <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN <br /> COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE <br /> OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION <br /> E CERTIFIES THE <br /> WORKO <br /> OFOR WIHIICH TIHIS CONTRACTOR'S HING <br /> S ISSSUED,,IIISHALL EMPLOY PERSONS SUBJECTSUBCONTRACTING TO WORKER'S COMPENSATION wI CERTIFY THAT IN PERFORMANCE OF THE <br /> LAWS O CAL CALIFORNIA."FORNIA <br /> APPLICANT'S SIGNATURE: <br /> n�� F �.h� TITLE n �.��P /�DATE <br /> Indicate the responsible party to be billed for additional 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 T R 17[. f—::7 l' - 5 Y 5 TE-1%k S <br /> Mailing Address 7)2jS ';�p LuU U <br /> Day Phone Number Cl 2)S18 1 C—) 9 <br /> Signature Date_ <br /> nEPu�E YYt E -H A tax L IA L- <br /> EH 23 008 (Rev 3/15/02) ESSEX AT F7fgCl L-I TZ� l fS S EC-n 0 <br /> w -� P <br /> ce <br />