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i <br /> 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-EHO REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PNS-END UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # GnLL`L�p(p�pj�j PROJECT CONTACT 6 TELEPHONE # �2L L�I� Lz�� -33yZ <br /> F FACILITY NAME �jc��CCA! 5T3�Tloh1 697 PHONE # 2L �( <br /> _,C, . ci ( <br /> A <br /> C ADDRESS �� ���CJ`CKCt— L.A/UE � �S z-ti <br /> I <br /> L CROSS STREET IVeNE- <br /> T OWNER/OPERATOR PHONE # <br /> C CONTRACTOR NAME Calif . Petroleum Equipment . Inc. PHONE # 209-276-1881 <br /> 0 <br /> N CONTRACTOR ADDRESS P • O.BOX 9364 Fres o Ca . <br /> CA Llc # 432613 CLASS A B, Haz . <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES N WORK.COHP.# 1 0 4 8 0 0 3 <br /> A PERMIT # <br /> C FIRE DISTRICT City of Lodi <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> C <br /> TANK ID # TANK SIZE L_ L� CHEMICALS TO BE STORED PROAOSEDDATETALLATION <br /> 39- zi - ''L <br /> 2V <br /> T 39- >` <br /> os� `1 <br /> N 39- ooaizj i <br /> K 39' v u <br /> 39- <br /> 39- <br /> III <br /> P <br /> L _ APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> IIIII111111111111111I I I I I I I I I U11 I I I I I I I I I ffffffl I I I I I I I I H I I I I I I I I I I I I I I I I <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 ORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS CALIFORN . ' <br /> APPLICANT'S SIGNATURE: C614 TITLE <E/Vl'%�tNIV4" OL- DATE I� l`5 3 <br /> Indicate the responsible rty 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 ��7�'f7in��= /NL x/771/, j���� (- L144s <br /> < <br /> Nailing Address <br /> Day Phone7(Rev <br /> r <br /> Date <br /> Signature T <br /> EH 23 0081/7/9 ) WP <br /> 3 <br /> ATTACHMENT #-5 <br />