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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # yALC L'Q'0 C� PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME 1�2)F CC PHONE # c <br /> A F-U <br /> C ADDRESS 1�C� j CHCL KL L LA/v L_ J =- L •� L("j Zty l <br /> I <br /> L CROSS STREET I/C/VE <br /> I <br /> T OWNER/OPERATOR PHONEIV <br /> # <br /> C CONTRACTOR NAME _ 7c� Fr— /I^J rl PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC # CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK ID # TANK SIZE (-C'A L� CHEMICALS TO BE STORED PROPOSED INSTALLATION w <br /> 39- ! DATE s <br /> T 39 — O 1� s L'�V lr . 5✓'t:,15 9 c- z- k-1 <br /> A 39- c:.(I :O,oat+ t�L�-5- <br /> N <br /> N 39- N( _ o ;Z I cmc ,. -._.Arwvr.nr.vrrx.�crr brVL 4 ;L,JL a <br /> K 39- D �C�: i o �a� ni`�� Ir 4 -� zi A Q <br /> 39- <br /> 39- <br /> P <br /> 9-39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED / <br /> A Z (SE TTACHMENT WITH CONDITIONS) DATE <br /> N PLAN REVIEWERS NAME ��- <br /> I I I I I I I I IRTIMM111 111111111111111111 111111111111IM11 <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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS Off-CALIFORNIA." <br /> J � <br /> APPLICANT'S SIGNATURE: c7TITLE DATE <br /> L I , fes <br /> Indicate the responsible arty to be bi led for additional PH -EHD staff time expended beyond the 8 hour minimum installation payment. <br /> The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name V L-;U&I AjA /NL tl ITAI, / fJ i�G-._ � <br /> Mailing Address � 25 72)ie0 �/ � 6W,yr-,-A : c 4 <br /> `, Z <br /> �� -3*' . <br /> Day Phone Number <br /> � <br /> �� <br /> Signature Date <br /> EH 23 008 (Rev 1/7/9 WP <br /> 3 <br />