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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 YEAR. A ONE MEI ONE YEAR IS <br /> MARREQUESTING Y BE GRANTED BYIS EXTENSION THIRTY EHD UPON RECEIPT FAYS F THIS P EIOR O THE END OF THE CALENDAR <br /> LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> CONTACT PHONE#9 <br /> PROJECT CONTACT: ,A)'Peg <br /> zoq- <br /> FACILITY PHONE# <br /> FACILITY NAME: A biv, ET <br /> A-" CROSS STII <br /> EET: <br /> FACILITY ADDRESS: v;2/ <br /> PHON5 �a <br /> OWNER/OPERATOR 1Nj9 <br /> CONTRACTOR NAME: PHONE: Glr 7 <br /> CP4TRACTOR ADL)RES' CA LICENSE# 7 OXq CLASS: <br /> HAZARDOUS WASTE CERTIFICATE: ES NO WORKERS COMP# <br /> FIRE DISTRICT: �PERMIT# <br /> BOARD OF EQUALIZATION # <br /> TANK ID# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE <br /> 12 lac (4 ,,e S—15--0-K <br /> D c7 <br /> S-C) <br /> nAPPROVED ❑APPROVED WITH CONDITIONS []DISAPPROVED <br /> (see attachment with conditions) <br /> i <br /> PLAN REVIEWER'S NAME DATE <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 /> LAWS WORKOFOR WHICH TIHIS PERMIT S ISSUED( I SH LL SUBCONTRACTING <br /> SUBIJECTTO WORKER'S COMPENE CERTIFIES THE SATION"I CERTIFY LAWS OF ATHAT <br /> FORNII E PERFORMANCE OF THE <br /> APPLICANT'S SIGNATURE: <br /> TITLE � DATE <br /> P <br /> Indicate the responsible arty to be billed for additional EHD staff time expended beyond the 8 hour minimum installation <br /> p <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> �L Name <br /> Mailing Address <br /> Day Phone Number <br /> � <br /> Signature <br /> LX <br /> EH 23 008 (Rev 3/15/02) <br /> 4 <br />