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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 <br />ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY <br />DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS <br />LETTER. <br />PROJECT CONTACT: M I o N A E LL'r0 4 <br />(�i/A <br />CONTACT PHONE # C116-31-3-11S-1- <br />r(,-31-3-rrsFACILITY <br />FACILITYNAME:E.cz L o o <br />1,�1 aT <br />FACILITY PHONE# z 0 q _ q 31 - 3 61 ( <br />FACILITY ADDRESS: <br />STOcIG rof-( CA 9S-zcs- <br />CROSS STREET: W r L c o X fZ. . <br />OWNER/OPERATOR: 13 r L L s C A r N L E- N o rz 3 Y <br />PHONE: 2 0 9- <br />CONTRACTOR NAME: (,(/ A c To r`l Esc , j ,.L F efz j,(C, <br />PHONE: 9 r 6 - 3 <br />CONTRACTOR ADDRESS: P-0- 6 o X 10>-5- <br />W- S AXc ro CA 9 S 64 ( <br />CA LICENSE # t <br />HAZARDOUS WASTE CERTIFICATE:S NO <br />WORKERS COMP # -4 r 3 q S z �- 0 <br />FIRE DISTRICT: <br />PERMIT # r P- p � 0 0 3$ 0 <br />BOARD OF EQUALIZATION # <br />TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br />0 1 /S"0010 Ips o c >a <br />- S &( , ,( o .S- <br />O'� !2 1 000 A- so C <br />/1'-00 5— <br />❑ APPROVED ❑ APPROVED WITH CONDITIONS ❑ DISAPPROVED <br />(see attachments) <br />PLAN REVIEWER'S NAME DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, <br />RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br />SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING "I CERTIFY THAT IN THE PERFORMANCE OF HE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSAT N LAWS OF ALIFO IA." <br />APPLICANT'S SIGNATURE <br />TITLE C 0 9--r 2 A -e o R-- DATE 4 Lq 4 S - <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 -hour <br />minimum installation payment. The party must acknowledge this responsibility for the additional billing <br />by signature and date below. <br />Name (Alp% C I'O &( Enc C. ! R r a4 Date q b r <br />Mailing Address < $10 Y, 0 Z S'- <br />Signature <br />'Signature klL� 15� �& 4, <br />C. REQUIRED SUBMITTALS <br />-3- <br />A-vl-o CA % S - <br />Daytime Phone '?t <br />