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cry <br /> 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 <br /> MAY 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 <br /> CALENDAR 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 /> PROJECT CONTACT: CONTACT PHONE # <br /> 1 l Iv 442$- 355- Z62f-o <br /> FACILITY NAME: FACILITY PHONE# <br /> Z-c:leU5�o�e ZZ - 7(a 20Ci - 235 - 3Z572_ <br /> FACILITY ADDRESS: 13cict VU. MIAI-J CROSS STREET: <br /> C,=1 ,A O►2 K� ra A e �)Z " <br /> OWNER/OPERATOR -7-E ►euejTic PHONE: X59 - ZL43 - 3-703 <br /> CONTRACTOR NAME: _ <br /> G ACtPQ- E u%a0 tM A �2v�C PHONE: qZS - 3 -S' z43ZCo <br /> CONTRACTOR ADDRESS: LALA t to %Ru5be l kZO, Su-4e A <br /> "UX%I�eo WA Z n- CA LICENSE # -Ncill 3 CLASS: <br /> TANK ID# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE <br /> I L Z� 000 GAsoL, we <br /> (0 ogo <br /> APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> (se attachment with conditions) <br /> PLAN REVIEWER'S NAME DATE <br /> -- —, --77-- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:"1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF <br /> CALIFORNIA." <br /> APPLICANTS SIGNATURE: f TITLEDia°E� iUrVS I�i9dJA�,PII1'ATE �Co"G 3 <br /> Indicate the responsible party to be billed for additional 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 G(aC�f�Z �YtJ('l r2CM��'►-Jery tl Ser?car ceS. -4nx , <br /> Mailing Address L 1/b 1�035e!/ 1� Hole-, ( f-e U A 987-13 <br /> Day Phone Number 4125- <br /> Signature Date_ �� 3 <br /> EH 23 008 (Rev 3/15/02) <br /> 4 <br />