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S3S1A 8]S/1IN83d <br /> ENVIRONMENTAL HEALTH DEPART wooz "uNOdIAN3 <br /> l�� <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLAT#N��F� t1Vl�fi <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 DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. <br /> PROJECT CONTACT: CONTACT PHONE# <br /> 209 . 577— C9CD <br /> FACILITY NAME: ST-ANt-4 mac. FACILITY PHONE# <br /> D t� <br /> FACILITY ADDRESS: CROSS STREET: <br /> 1 13 W 1_ATNtzdP U N I o" f� <br /> OWNER/OPERATOR: PHONE: <br /> 7.Lx1 •S-7'7. 6i0cx=> <br /> CONTRACTOR NAME: PHONE: <br /> LC_ 4S E V-VL c-Z- S7�5� - I "30 <br /> CONTRACTOR AD RESS: CA LICENSE# <br /> '7 -7-�012-4-—7 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> YES NO W (4p -7ZS'- <br /> FIRE DISTRICT: PERMIT# <br /> GI oP MA-4-riz .A oG - t t <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> FA-051 549 y a to �N Zoo <br /> CA o Cdd Es (_ ZOo <br /> 'rA o i it c.- O <br /> ❑APPROVED BIAPPROVED WITH CONDITIONS ❑DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME A4, DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED., I SHALL NOT EMPLOY <br /> ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE <br /> OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature <br /> Title O Date <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8-hour minimum installation <br /> payment.The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name (_._AIZ• CAQp4E7�7-jEjZ_ Date <br /> Mailing Address 315 Vs Lti—h -t t4E CA '9x722 <br /> Signature Daytime Phone S" 1130 <br /> Revised 07/31/08 3 <br />